Disentangling the effects of strategies for guideline implementation in school health services: A hybrid type 2 cluster-randomized factorial trial

Disentangling the effects of strategies for guideline implementation in school health services: A hybrid type 2 cluster-randomized factorial trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Disentangling the effects of strategies for guideline implementation in school health services: A hybrid type 2 cluster-randomized factorial trial Åse Sagatun, Malene Brekke, Carina Lisøy, Tore Wentzel-Larsen, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9198555/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: Translating evidence-based guidelines into actionable improvements and sustained behavior change in practice remains a critical challenge across sectors. Evidence on strategies commonly used to disseminate and implement guidelines is scarce, and studies testing the effects and interactions of discrete and blended strategies are called for. This study disentangled a co-created blended implementation strategy into its discrete dissemination and implementation strategies: Audit and feedback+, Ongoing consultation, and Active dissemination. We examined the individual and interactional effects of these strategies on fidelity to a national guideline for health consultations with 8th -grade students in the Norwegian school health services. Methods: A hybrid type 2 cluster-randomized factorial trial was conducted in 25 municipalities and 49 schools. Three dissemination and implementation strategies constituted the experimental factors, yielding eight experimental conditions with different combinations of the strategies schools were randomized to. A total of 56 school nurses conducted consultations with 1400 students. Students and school nurses completed questionnaires at the beginning of the school year and after the 8th -grade consultation. Fidelity to the guideline for 8th -grade consultations was assessed by evaluating adherence to recommendations, the quality of adherence, and consultation duration. Linear mixed effects models were used to examine the effects. Results: School nurses and students reported moderate to high guideline fidelity across conditions, and few differential effects were found. Only the Audit and feedback+ strategy had a significant main effect on adherence, which was negative: nurses with Audit and feedback+ addressed fewer guideline-recommended themes during consultations. Conclusions: No convincing differential or additive effects of the dissemination and implementation strategies on guideline fidelity were observed, which was generally high. Frequent fidelity measurement may itself have functioned as an implementation strategy, whereas Audit and feedback+ appeared to facilitate prioritization of consultation content without improving consultation quality. Overall, the study points to the importance of parsimony and mechanism-focused evaluation when designing and testing strategies for implementing evidence-based guidelines. Trial registration ISRCTN reg.nr. 24173836 Implementation strategies Implementation mechanisms Guideline Fidelity School health services EPIS-framework Multifactorial design Hybrid type 2 Figures Figure 1 Figure 2 Contributions to the Literature • Implementation strategies are often delivered as multi-component “packages,” but the added value of combining strategies is rarely tested using rigorous experimental designs. • This study applies a factorial trial to disentangle three commonly used dissemination and implementation strategies and examine their individual and combined effects. • The findings challenge the assumption that more support automatically leads to better guideline fidelity and highlight that some strategies may shift provider priorities rather than uniformly improve practice. • The study underscores the importance of parsimony and mechanism-focused evaluation when designing and optimizing implementation strategies. Background Best-practice guidelines intend to support decision-making in health and welfare services. Their overarching aims are to improve service quality and equity ( 1 ). Best-practice guidelines that are evidence-based are developed through rigorous processes of systematically reviewing and appraising relevant research, contextualizing evidence, and co-creation among selected content area experts such as researchers, health professionals, representatives of service recipients, and advocates ( 2 , 3 ) These processes are designed to ensure guidelines are effective, safe, contextually relevant, and equitable. Despite the considerable investments made into developing and disseminating evidence-based guidelines, translating guidelines into actionable improvements and behavior change in services remains a critical hurdle across health sectors ( 4 ). The dissemination of guidelines to target audiences is often the only implementation strategy employed, although it is widely considered a necessary, but insufficient, strategy for effective and sustained implementation ( 5 – 8 ). Consequently, the guidelines' impact on service delivery is limited by ineffective or lacking implementation strategies. The effort put into developing the guidelines is rarely matched by similar efforts to develop recommendations for implementing them ( 4 , 9 ). A systematic umbrella review of the literature indicates that ( 1 ) a variety of bundles of different dissemination and implementation strategies can improve the implementation of guidelines, and ( 2 ) the comparative effectiveness between different strategies is largely unknown ( 4 ). Other comprehensive systematic reviews on implementation strategies in general (i.e., not limited to guidelines as the implementation object) come to similar conclusions ( 10 , 11 ). Additionally, implementation strategies tend to be evaluated as multifaceted packages (i.e., bundles and blends of discrete strategies), and how individual strategies and different combinations contribute to effectiveness is uncertain ( 4 , 10 , 11 ). Thus, research testing the effectiveness, mechanisms, and interactions of common combinations of implementation strategies is called for to inform the design of effective and efficient dissemination and implementation strategies ( 11 – 15 ). In the current study (the GuideMe trial) ( 16 ), a blended implementation strategy was co-created to implement recommendations in a new national guideline for school health services. Subsequently, the strategy was disentangled into its most meaningful discrete parts and tested in all possible combinations through a factorial trial. National Guideline for Health-Promoting Consultations in School Health Services The school health service is a free-of-charge health service available for children and adolescents in Norwegian schools. School nurses working within this service operate at individual, group, and universal levels, providing services such as individual consultations on health and well-being and classroom health literacy teaching ( 17 ). In 2017, the Norwegian Directorate of Health disseminated a new national guideline for school health services ( 18 ). The guideline serves as a professional standard, and any service choosing to deviate from this standard is expected to document and justify the decision. The guideline strongly recommends that school nurses offer individual, health-promoting consultations to all 8th -grade students. These consultations aim to strengthen students’ life skills, provide an overview of the student population, identify those in need of follow-up, and actively engage students in the process. However, the guideline does not provide recommendations regarding its implementation. The SchoolHealth implementation strategy and its disentanglement SchoolHealth is a co-created, blended implementation strategy designed to support and promote the use of the new national guideline by school nurses with fidelity ( 16 ). Using a framework for disentangling implementation strategies ( 12 ), SchoolHealth was decomposed into what we considered to be its three most discrete meaningful parts (i.e., implementation elements). Discrete parts, or sets of parts, are considered meaningful elements of implementation when they do not, in theory, necessarily rely on other parts to compose a whole that can influence implementation determinants and outcomes ( 12 ). Thus, meaningful implementation elements, such as discrete strategies, have a defined or assumed functional or mechanistic relationship with relevant implementation determinants and/or outcomes. Two of the disentangled elements in SchoolHealth were defined as implementation strategies, while one element was defined as a dissemination strategy. The implementation strategies were ( 1 ) an audit and feedback system with a digital administration and dialogue tool (Audit and feedback+), and ( 2 ) ongoing external consultation with e-learning preparations (Ongoing consultation). The dissemination strategy ( 3 ) included dissemination of educational videos and materials to support collaboration between school nurses and school personnel in line with guideline recommendations (Active dissemination) ( 16 ). The current study The objective of the study was to advance scientific knowledge about the effectiveness and mechanisms of strategies commonly used to disseminate and implement guidelines in primary healthcare and school settings. The GuideMe trial was designed to optimize strategies for implementing recommendations in the new national guideline by investigating the effectiveness and interactions of the discrete elements that make up the blended SchoolHealth strategy. We tested the individual and interactional effects of three dissemination and implementation strategies (D&I-strategies) on fidelity to the guideline recommendation for conducting health consultations with all 8th -grade students. Methods Design We conducted a hybrid type 2 cluster-randomized factorial trial within the school health service, and this paper presents results from the implementation part of the hybrid trial. As each of the three discrete D&I-strategies in SchoolHealth had two levels (yes/no, 2ᵏ) there were eight (2x2x2) possible experimental conditions (see Table 1). The design enables assessment of each individual factor’s performance (i.e., main effects), as well as examination of whether the factors interact to influence outcomes (i.e., interaction effects) (19). Figure 1 depicts theorized relationships between the guideline recommendation, D&I-strategies, implementation determinants, and outcomes. The content, actors, and aims for each strategy are specified in Table 2. The Exploration, Preparation and Implementation framework (EPIS) (20) was used to guide the implementation process, while EPIS and the Capability, Opportunity, Motivation – Behavior theory (COM-B) (21) informed tailoring of strategies, development of a theoretical model, and measurement of determinants and outcomes. Complete details about the theoretical foundations and development of the GuideMe trial can be found in the protocol (16). Insert Figure 1 here - Figure 1: Logic model that shows the theorized relationships between the guideline recommendations, D&I-strategies, implementation determinants, and outcomes (full model for the whole study, see protocol (16)). Insert Table 2 here - Table 2: Specification of Implementation and Dissemination Strategies (D&I strategies) Setting The study was conducted in Norwegian lower-secondary public schools and school health services. Norway's school system is predominantly public, with the first ten years of education being mandatory. The school health service is part of the primary municipal health care services and aims to promote good health and prevent disease (17, 18). The Norwegian Directorate of Health has estimated a staffing norm for the school health service, which for lower secondary schools corresponds to one full-time school nurse per approximately 330 students. Staffing levels of school nurses in Norwegian schools vary across municipalities (22). In this sample, about 45% of schools had a school nurse at or above the recommended norm. Interventions: Guideline recommendations The national guideline for the school health service strongly recommends an 8 th -grade health consultation with all students, and outlines goals (see introduction) and content for the consultations. During the consultation, the school nurses are to inspect postural assessment (scoliosis evaluation), measure weight and height, and address themes in the following categories: Coping, well-being, and relationships; sleep and sleep habits; diet and meals; physical activity, leisure activities, and sedentary behavior; dental health; sexual health; tobacco, alcohol, and other substance use; violence, abuse, and neglect; and provide information about the general practitioner scheme. The guideline further states that consultations should strengthen user involvement in the consultation and be based on students’ needs and preferences. The consultation is estimated to last approximately 30 minutes (18). Dissemination and implementation strategies The three SchoolHealth D&I-strategies tested as factors in the trial (16) were: Audit and feedback+ ( A&F ) Before the 8 th -grade consultation, students completed a digital health form covering themes to be addressed in the consultation, which generated a color-coded individualized feedback report for the school nurse. The feedback report intended to provide school nurses with an overview of the students’ health and well-being and help tailor the consultation to the students’ needs and preferences. After the consultation, both students and school nurses evaluated fidelity to the guideline and user satisfaction via digital questionnaires, producing a consultation report and a user satisfaction report . These, along with an aggregated school report based on students’ health forms, were available to school nurses and service leaders through the A&F platform (16). Ongoing consultation Ongoing consultation aimed to strengthen school nurses’ motivation and capabilities to follow the 8 th -grade consultation guidelines. It included an e-learning module covering theory and instructional videos, a series of three digital or hybrid group consultations based on a reflexive team approach (23), and one wrap-up session. Each group consultation involved 5–7 school nurses and lasted about 2.5 hours (16). Active dissemination The Active dissemination strategy (i.e., planned, targeted, and proactive effort to spread and promote the use of innovations (24), provided web-based resources to support interprofessional collaboration between schools and the school health service. The materials encourage regular collaboration meetings throughout the school year, beginning with the first of the four sessions at the start of the school year. Participants were encouraged to view the instructional videos and to work together on shared tasks in the meetings (16). This strategy was not designed to influence fidelity to guideline recommendations for the 8 th -grade consultations directly. Instead, it was designed to promote interprofessional collaboration, which is another recommendation in the new national guideline that will be addressed in a separate publication. With the three D&I-strategies serving as experimental factors, participants received condition-specific information and introductory training relevant to their allocated condition. All participants also attended a kick-off meeting where they received standardized information about the new national guideline and recommendations, and training in the electronic data collection system. Participants and Location The study gathered data from 8 th -grade students and school nurses in southeastern and central Norway, encompassing both rural and urban areas. The participating schools had between one and four parallel 8 th -grade classes. In Norway, 8 th -graders are generally 12 to 13 years old. Data collection spanned two school years (2022/23 and 2023/24), with each school participating for one year. Two-thirds of the municipalities participated in the final school year. Measures Background of participants Students and school nurses responded to questions about several background variables at the beginning of the school semester (T1). Students reported their home language, perceived family economic status, and living arrangement (e.g., with both parents or otherwise). The student’s gender was registered by the parents during the consenting process (boys, girls, or neither). School nurses stated their age and years of professional experience. Implementers’ fidelity to dissemination and implementation strategies We applied a combination of monitoring and post-measures to assess implementers’ fidelity to the components of the D&I strategies. For each condition, research coordinators monitored adherence to implementation plans (structure, content, dosage, absenteeism), coded adaptations as fidelity consistent or inconsistent, registered details about technical assistance provided, and registered unexpected events and circumstances that may affect fidelity (i.e., emergent events). A simplified version of The Framework for Reporting Adaptations and Modifications to Implementation Strategies (FRAME-IS) (25) was used for coding and judging adaptations and emergent events. Research staff and supervisors self-reported on adherence, quality, and adaptations in delivering training and supervision (see Appendix 1). An implementation specialist (TE) reviewed all monitoring and coding and clarified questions and details with coordinators or research staff. School nurses’ engagement in dissemination and implementation strategies School nurses responded to post-measures (at the end of the school year, T3) about their engagement with different components within the three D&I strategies. Complete details about implementation fidelity and engagement measurements are available in the study protocol (16). Fidelity to guideline recommendations (Adherence, Quality, Duration) Fidelity to the guideline was evaluated by assessing school nurses’ adherence to the recommendations for 8 th -grade consultations, the quality with which these recommendations were implemented, and the duration of each consultation. Complete details on the conceptualization and measurement of guideline fidelity are available in the protocol (16). Fidelity was measured using self-reports from school nurses and corresponding reports from students, both collected immediately after each consultation (T2). The scale-ranges for these fidelity measures are presented per informant type in Table 3, and a description of the items covering the measures is provided in Appendix 2. Adherence Total adherence to guideline recommendations was assessed using checklist items covering key recommendations (see Appendix 2 for coding details). This included items on measuring height and weight, and a postural assessment ( Adherence to physical assessments ), and whether the eight main conversational themes recommended to be covered were addressed during the consultation (Adherence to themes ). All items were self-developed and were user-tested for relevance and clarity by both students and school nurses. Quality The Quality of how the recommendations were addressed was measured through school nurses’ and students’ reflections on Q uality in adherence and T ailoring of the consultation, as well as students’ perceived A lliance with the school nurse. The items were adapted from user experience measures previously applied in Norwegian health services (26, 27), and based on the national guideline (18). All items were rated on a 5-point scale (from 0-4). Quality in adherence assessed whether the conversation facilitated a health-promoting dialogue. Specifically, they assessed the extent to which tailored health information was provided, whether positive habits were acknowledged, and whether the nurse actively listened to the student. Additionally, the items evaluated the extent to which the student gained insight into healthy behaviors and perceived the consultation as a safe and supportive experience. Tailoring assessed whether the school nurse centered the conversation on what mattered to the student, acknowledged positive habits, and provided tailored health information. Students responded to additional items about their perceptions of Alliance with the school nurse as an indicator of quality in school nurses’ use of guidelines (the items are reported in Appendix 2). Duration School nurses reported the time spent on student consultations ( duration ) immediately after each consultation (in minutes) (T2). Sample size We used the R-package MOST (28) for sample size estimation. We assumed a two-sided 5% alpha-level, an effect size of d = 0.30, and statistical power of 0.80 (β = 0.20). As data was hierarchical, we accounted for an intraclass correlation coefficient (ICC) of 0.05 and assumed an average cluster size of 30 (SD = 15) (29). In 2 ᵏ factorial designs (as applied in this study), the statistical power to detect main effects and interaction effects is approximately equivalent (30). The power calculations indicated that 36 schools and 1,080 students were required for the study. To accommodate potential dropouts and the need for subgroup analyses, we aimed to recruit approximately 40 schools and 1,200 students. Enrollment School health services in Southeastern and Central Norway were invited to participate in the GuideMe trial. Information meetings were held with 40 services in Southeastern and Central Norway. Of these, 26 joined the study, involving 56 school nurses and 49 schools. These represented both large and small municipalities in urban and rural areas. All students, in the classes selected by the school, were invited to participate ( N = 2079). Recruitment procedures are described in the study protocol paper (16). Randomization The schools were randomly assigned to different combinations of the three D&I-strategies in SchoolHealth (16). The procedure was carried out in R using a function specifically written for the GuideMe study (see syntax in Appendix 3). The function was developed by a statistician in collaboration with key personnel in the project and was witnessed by an independent third party. The schools were randomized to one of the eight experimental conditions (see Table 1). Statistical methods We used linear mixed effects models to examine the individual (main) and interaction effects of the three study factors. Separate models were estimated for each outcome using both students and school nurses as informants about the 8 th -grade consultation. To account for clustered data, random effects between school nurses were included. The main independent variables were effect-coded variables for the three study factors and their products, as described by Kugler, Dziak & Trail (31). For each factor, one level was coded –1 (off), and the other as 1 (on) (Effect coding matrix, see Appendix 4). Interaction terms were computed as the products of the effect-coded variables for the main effects. With effect-coding for two-level factors, multiplying the coefficients by a scaling constant of 2 yields the estimated main and interaction effects. Main effects were interpreted as the average change in the outcome variable associated with receiving a given factor compared to not receiving it, averaged across all levels of the other factors (19, 32). Two-way interaction effects were interpreted as indicating whether the effect of one factor depended on the level of another factor, averaged over the levels of the remaining factor. A three-way interaction was interpreted as the two-way interaction effect being different depending on the level of the third factor. In supplementary analyses, we examined interactions between the effects and sex, to explore potential differences reported by boys and girls. All analyses were conducted in R version 4.2.1. (The R Foundation for Statistical Computing, Vienna, Austria). Mixed effects analyses were fitted using the nlme package (33). Results Description of the participants In total, 1400 8th -grade students (67% of the invited) and 56 school nurses from 48 schools answered the questionnaire after the 8th -grade consultation. The participant flow is illustrated in Fig. 2 . Insert Fig. 2 here - Figure 2 : Flow-chart of the participants in the study The number of school nurses conducting the 8th -grade consultations at each school was one (n = 41), two (n = 6), or three (n = 1). The mean age of the school nurses was 43.5 years (range: 27–64) and their mean professional experience was 8 years (range < 1–28). Among the students, 704 (49.5%) identified as boys, 715 (50.2%) as girls, and 4 (0.3%) as neither. Based on visual inspection of descriptive statistics, the students` self-perceived family economy, home language, and living arrangements appeared comparable across the D&I strategies (Table 4 ). Insert Table 4 here - Table 4 : Participant characteristics and description of Fidelity, by D&I strategy Implementers' fidelity to dissemination and implementation strategies and emergent events Implementers’ fidelity to D&I strategies was high for all conditions, and the large majority of adaptations were considered fidelity-consistent. Three adaptations were fidelity-inconsistent but judged to have limited impact on experimental validity (details available in Appendix 1). Seven emergent events (e.g., turnovers, crises, technical issues) may have influenced implementation fidelity (ranging from 0–2 events in each condition), most notably in the condition with all three strategies/factors and the condition with active dissemination only. Requested technical assistance relevant to the experimental conditions varied. The condition with all three D&I strategies had 13 instances of receiving technical assistance (phone calls and emails). The active dissemination-only condition had seven such instances, and the condition with A&F and Ongoing consultation had five. The remaining conditions had two or fewer instances of relevant technical assistance. Complete implementation fidelity results for each strategy component in each condition are available in Appendix 1. School nurses’ engagement in the Dissemination and Implementation strategies The school nurses’ engagement varied between implementation strategies and across components within implementation strategies; full details are provided in Appendix 5. Overall, engagement was considered moderate to high for the A&F strategy and the Ongoing consultation strategy, and low in the Active dissemination strategy. The A&F strategy consists of several reports, and most school nurses used the Individualized feedback report for both preparation and completion of the consultations with students. The majority of school nurses also used the School report and User satisfaction report, while the Consultation report was used less frequently. Concerning the Ongoing consultation strategy, most school nurses reported high engagement with the e-learning modules. However, about half did not complete the e-learning before the consultations, as planned. Participation in the consultation sessions was generally high, about 90% attended two or more of the three sessions. In contrast, the collaboration meetings in the Active dissemination strategy were held less frequently than planned. Twenty-six percent of school nurses did not attend any meetings, 26% attended one, and 33% attended three or more meetings (see details in Appendix 5). Fidelity to the 8th -grade recommendations The mean adherence score, representing the number of recommended themes addressed during the 8th -grade consultation, was 6.39 as reported by school nurses and 5.20 as reported by students (Table 4 ), corresponding to 80% and 65% of the maximum possible score, respectively. For the school nurses, the mean quality in adherence score (Table 4 ) corresponded to 67% of the maximum possible score, and for students the corresponding score was 76% of maximum, indicating generally favorable perceptions of consultation quality. The mean score for tailoring the consultation to students’ individual needs was equivalent to 68% and 64% as reported by school nurses and students, respectively. On average the 8th -grade consultations lasted for 30.2 minutes (SD = 12.2). These ratings suggest an overall moderate-to-high level of perceived fidelity from both perspectives, with students reporting fewer themes covered and higher quality in the adherence to the 8th -grade consultations than school nurses. Description of fidelity to the 8th -grade recommendation, organized by experimental group for both students and school nurses, is presented in Appendix 6. Effects of the dissemination and implementation strategies We found a statistically significant main effect of A&F on both Total adherence to key recommendations, and Adherence to themes , as reported by both school nurses (Table 5 ) and students (Table 6 ). Specifically, school nurses using the A&F addressed fewer themes in the consultation compared to those who did not use this tool. Insert Tables 5 and 6 here - Table 5 : Effect of the of the Dissemination & Implementation Strategies on fidelity to the guideline, reported by School health nurses. Table 6 : Effect of the of the Dissemination & Implementation Strategies on fidelity to the guideline, reported by student. We found no other significant main effects of the D&I strategies on any of the outcome measures (duration, quality, tailoring and alliance) reported by school nurses or students (Tables 5 and 6 ). However, a small statistically significant two-way interaction was found between Ongoing consultation and Active dissemination reported by students for Quality ( p = 0.013 ), Tailoring ( p = 0.041 ) and Alliance ( p = 0.042 ) (Table 6 ), with the effect of each of these two factors being reduced when the other one was present, compared with when it was not present. School nurses’ reports did not support this finding. Additionally, as described above, the main effects of the Ongoing consultation and Active dissemination were not significant for any of the outcomes. Taken together, this isolated antagonistic interaction, observed only in student reports and in the absence of corresponding main effects, does not suggest a consistent or actionable antagonistic relationship between these two strategies. In supplementary analyses examining whether student-reported effects varied by sex (boys/girls), no significant interactions between effects and sex were found for Total Adherence (lowest p = .226), Adherence to themes (lowest p = .257) or Quality (lowest p -value .108). For the subscale Alliance , the three-way interaction differed significantly by sex ( p = .018), but was not statistically significant within either groups when studied separately: boys (estimate 0.09, CI [-0.30, 0.49], p = .631), girls (estimate − 0.37, CI [-0.75, 0.02], p = .062), though a somewhat low p -value for girls was noted Discussion This factorial trial estimated the main effects and interactions of three common dissemination and implementation strategies – A&F, Ongoing consultation, and Active dissemination – on school nurses’ fidelity to guidelines for health consultations with students. The strategies produced few differential effects. The only strategy that had a statistically significant effect, compared with the average of the other two, was the A&F strategy’s effect on adherence to content in the consultation. School nurses using the A&F strategy addressed fewer themes in the consultation than those without. Overall, moderate to high fidelity to the consultation guideline was reported by both the school nurses and students across all experimental groups. Effects of the dissemination and implementation on fidelity to the 8th -grade consultation recommendation Our findings challenge the assumptions that A&F generally enhance guideline adherence ( 34 ). A likely explanation is that the individualized reports helped school nurses prioritize specific themes. These reports provided color-coded feedback summarizing scores on students’ health, well-being, health literacy, and needs. The report may have nudged nurses to focus on seemingly more relevant themes while disregarding others. The findings are consistent with the clinical performance feedback intervention theory ( 35 ) suggesting that feedback interventions are most effective when they directly support actionable behaviors. The individualized report in the A&F platform provided immediate suggestions regarding appropriate themes to prioritize and was widely used by the school nurse both in preparation for and during student consultations. These report features align with CP-FIT theory, suggesting that actionability is the primary mechanism in such behavioral induction. This interpretation is further supported by a recent systematic review concluding that A&F is most effective when designed to help recipients prioritize and take action ( 34 ). This may explain why school nurses using the A&F platform addressed fewer topics during consultations than nurses without the platform. The guideline recommends tailoring the consultations to students’ needs, but without specifying how and when to tailor. The drift in adherence to guideline themes may therefore reflect what school nurses deem appropriate tailoring in line with recommendations. Considering the limited time available for each consultation ( M = 30.2 minutes, SD = 12.2), and the number of themes ( 8 ) and physical assessments ( 3 ) recommended to be addressed in the consultation, feedback-informed prioritization may also have been considered necessary for the overall quality of the consultation and tailoring. However, the A&F strategy did not significantly affect students’ or nurses’ perceptions of tailoring, nor the quality or duration of the consultations. Thus, in this case, the highly actionable feedback may have led to prioritization of themes at the expense of comprehensive adherence to all themes outlined in the guideline. Apart from adherence to themes, no significant main effects were observed across strategies on any of the constructs indexing guideline fidelity, including quality in the use of guideline recommendations, tailoring to students' needs, or alliance between students and nurses. Although this dismantling factorial trial was exploratory, these findings may be considered notable considering the current literature. A&F is widely regarded as a potent and empirically well-supported implementation strategy ( 34 ). The A&F strategy in the current study was co-designed and tailored to include the core elements and primary mechanisms that contemporary theory posits are essential for A&F to exert effects (i.e., behavioral induction and alignment with identity, culture, and capacity limitations ( 35 ). Consequently, stronger main effects with this strategy were perhaps expected. However, our results provide only partial support for A&F as a potent strategy, likely due to the actionability mechanism proposed by CP-FIT. Consultation is a common element in effective implementation strategies ( 12 , 36 ) and there are several potential mechanisms by which Ongoing consultation can influence fidelity to interventions and guidelines ( 37 ). The limited effects of Ongoing consultation, contrast these theories suggesting that sustained support and reflective practice are key drivers of fidelity ( 36 , 37 ). However, in this trial, nurses across conditions appeared to have baseline motivation and a supportive climate for implementing the national guideline ( 38 ). This might have reduced the effect of the Ongoing consultation strategy compared with the average of the other two. The Active dissemination strategy in the study has, in contrast to the two implementation strategies, no theoretical mechanisms directly linked to fidelity to the recommendations for the 8th -grade consultation. Still, this strategy did not affect fidelity to the 8th -grade recommendations differently than the two implementation strategies (combined). We caution against interpreting these results as “anything goes,” or as dissemination being as effective as more active implementation strategies. To our understanding, the results are more likely to be explained by methodological limitations, particularly by intervention effects arising from fidelity measurement. Methodological considerations All school nurses completed fidelity assessments immediately after each consultation. These measurements may have functioned as an intervention itself. Responding to items about fidelity to guideline recommendations may have increased awareness of expected consultation content, prompted reflection, and encouraged changes in practice, regardless of experimental group. This reactive measurement effect may partly explain the moderate-to-high overall fidelity scores observed in the study, which were higher than those typically reported in a previous study in the service ( 39 ). The relatively high fidelity score across all experimental groups may also reflect that school nurses participating in the study already had strong baseline motivation and capacity to implement the guideline recommendations, and that the frequent fidelity measurements served as reminders or nudges that facilitated fidelity. Despite the methodological considerations, our findings align with reviews that highlight the uncertainty surrounding the added value of multi-component strategies ( 10 , 11 ). A&F remains one of the most evidence-supported implementation strategies, yet effectiveness varies by context, design, and aim ( 34 ). Our results suggest that when A&F emphasizes prioritization, it may inadvertently compromise comprehensiveness. This may imply that guideline development should specify how guideline recommendations should and should not be tailored, with corresponding implications for the design of feedback interventions. Implications Several implications can be drawn from the results. First, relatively strong fidelity across conditions highlights school nurses as capable implementers of national guidelines. Frequent self-report audit or reminders of core guideline recommendations in this context can seemingly go a long way, while additional implementation strategies may serve more as fine-tuning supports than as essential preconditions for adoption. This has relevance for policy: investing in tailored A&F or reminders integrated into workflow structures, such as medical records in the health care service, may be more cost-effective than multi-component strategies that require ongoing external implementation support. Second, and relatedly, the design of A&F strategies, and implementation strategies in general, should be mindful of potential unintended consequences as a function of seemingly positive design features such as high actionability. User-friendly feedback systems can serve as choice architecture, automatically steering provider behavior. In the case of guidelines, A&F designers may consider incorporating prompts that ensure broad coverage of core guideline recommendations, while still allowing for prioritization of individual student needs. Third, the absence of clear additive or synergistic effects of combining strategies suggests that efficiency and parsimony in implementation support are important. Rather than assuming more is better, future research should continue to disentangle strategies and test mechanisms ( 13 ), as recommended in implementation optimization frameworks ( 40 ) and common elements approaches ( 12 ), and also test how and when blended implementation strategies (i.e., consciously designed “packages/programs” of implementation strategies) are greater than the sum of their parts. Conclusions This trial did not find convincing evidence of differential or additive/interactional effects between A&F, Ongoing consultation, and Active dissemination on fidelity to guidelines. While overall fidelity to the guideline recommendations was relatively high, the Audit and Feedback+ strategy appeared to shift the balance of consultation content rather than uniformly improving fidelity. Neither Ongoing consultation nor Active dissemination produced consistent additional benefits. These findings underscore the importance not only of comparing strategies but also of understanding how and when they influence provider behavior and student experience. Abbreviations A&F Audit and Feedback+ COM-B Capability, Opportunity, Motivation – Behavior theory D&I-strategies Dissemination and Implementation strategies EPIS The Exploration, Preparation, Implementation, and Sustainment framework FRAME-IS The Framework for Reporting Adaptations and Modifications to Implementation Strategies Declarations Ethics approval and consent to participate The study was reported to the Norwegian Regional Committees for Medical and Health Research Ethics for approval. They concluded that the project fell outside the scope of the Norwegian Health Research Act, cf. § 2, and could therefore be conducted without their approval. The study followed Norwegian procedures for ethical evaluation and was carried out in accordance with the Norwegian ethical guidelines for research (41). Data protection was assessed by Sikt – The Norwegian Agency for Shared Services in Education and Research. Informed consent was obtained from all participants, and parents of 8 th -grade students. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Availability of data and materials The datasets generated and analyzed during the current study are not publicly available due to the General Data Protection Regulation laws but may be provided by the corresponding author on reasonable request. Any materials related to the dissemination and implementation strategies can be provided by the corresponding author on reasonable request Funding The study was primarily funded by the Norwegian Research Council (grant number 320097). Furthermore, the participating research institutions RBUP, NTNU, and VID provided additional support, primarily through the allocation of personnel resources. Authors' contributions ÅS, TE, CL, TWL and MB drafted the manuscript with input from all authors. All authors critically revised the manuscript and approved the version submitted. ÅS, CL, TWL, TE and MB undertook the analyses and prepared the tables and figures. ÅS, SH, KWG, MB, SE and TE have been involved in the development of the implementation strategies (SchoolHealth). ÅS, SH, TE, MB, KWG, HS and SE have been involved in the choice and refinement of assessments and defining mechanisms. ÅS, SH, TE, HS and SE have been involved in the design of the study. ÅS, SH, KWG and ALA have been involved in the data collection/weekly follow-up of the study. ÅS is the principal investigator of the GuideMe study. Acknowledgements We extend our sincere gratitude to all adolescents, school nurses, leaders, and school personnel who have collaborated with us or provided invaluable feedback throughout the development of SchoolHealth and the assessments used in this study. We are grateful to the Research and Innovation Development Team at RBUP for their work developing the quantitative data collection platform and the technical solution in the Digital Feedback and Administration Tool. Finally, we wish to acknowledge Carsten Obel, who is sadly no longer with us, for his longstanding dedication to research aimed at promoting the health of young people and the services that support them. He played a key role in initiating this project, and his contributions continue to inspire our work. References World Health Organization. Health for the world’s adolescents: a second chance in the second decade. Geneva: WHO; 2014. National Institute for Health and Care Excellence (NICE). Developing NICE guidelines: the manual. 2014. Available from: https://www.nice.org.uk/process/pmg20 . Accessed 27 Feb 2026. Norwegian Directorate of Health. Manual for developing evidence-based guidelines [Veileder for utvikling av kunnskapsbaserte retningslinjer]. 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Dissemination, implementation and impact of the ESHRE evidence-based guidelines. Hum Reprod Open. 2019;2019(3):hoz011. Gagliardi AR, Brouwers MC. Do guidelines offer implementation advice to target users? A systematic review of guideline applicability. BMJ Open. 2015;5(2):e007047. Boaz A, Baeza J, Fraser A, Persson E. ‘It depends’: what 86 systematic reviews tell us about what strategies to use to support the use of research in clinical practice. Implement Sci. 2024;19(1):15. Ashcraft LE, Goodrich DE, Hero J, Phares A, Bachrach RL, Quinn DA, et al. A systematic review of experimentally tested implementation strategies across health and human service settings: evidence from 2010–2022. Implement Sci. 2024;19(1):43. Engell T, Stadnick NA, Aarons GA, Barnett ML. Common elements approaches to implementation research and practice: methods and integration with intervention science. Glob Implement Res Appl. 2023;3(1):1–15. Geng EH, Powell BJ, Goss CW, Lewis CC, Sales AE, Kim B. 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Coding and interpretation of effects in analysis of data from a factorial experiment. In: Collins LM, Kugler KC, editors. Optimization of behavioral, biobehavioral, and biomedical interventions: advanced topics. Cham: Springer; 2018. p. 175–205. Montgomery DC. Design and analysis of experiments. Hoboken (NJ): John Wiley & Sons; 2017. Pinheiro J, Bates D. nlme: linear and nonlinear mixed effects models. R package version 3.1–168; 2025. Available from: https://cran.r-project.org/web/packages/nlme/index.html . Accessed 27 Feb 2026. Ivers N, Yogasingam S, Lacroix M, Brown KA, Antony J, Soobiah C, et al. Audit and feedback: effects on professional practice. Cochrane Database Syst Rev. 2025;3(3):CD000259. Brown B, Gude WT, Blakeman T, van der Veer SN, Ivers N, Francis JJ, et al. Clinical performance feedback intervention theory (CP-FIT): a new theory for designing, implementing, and evaluating feedback in health care based on a systematic review and meta-synthesis of qualitative research. Implement Sci. 2019;14(1):40. Tugendrajch SK, Sheerin KM, Andrews JH, Reimers R, Marriott BR, Cho E, et al. What is the evidence for supervision best practices? Clin Superv. 2021;40(1):68–87. Nadeem E, Gleacher A, Beidas RS. Consultation as an implementation strategy for evidence-based practices across multiple contexts: unpacking the black box. Adm Policy Ment Health. 2013;40(6):439–50. Sagatun Å, Wentzel-Larsen T, Engell T. Implementation of guidelines in school health services: leadership and climate [Implementering av retningslinjer i skolehelsetjenesten: ledelse og klima]. Nor J Clin Nurs. 2026. In press. Waldum-Grevbo KS. Public health nurse: are you following the new national recommendations? [Helsesøster: følger du de nye, nasjonale anbefalingene?] Sykepl Fag. 2018;106:70773. Guastaferro K, Collins LM. Optimization methods and implementation science: an opportunity for behavioral and biobehavioral interventions. Implement Res Pract. 2021;2:26334895211054363. National Committee for Research Ethics. General guidelines. 2019. Available from: https://www.forskningsetikk.no/en/guidelines/general-guidelines/ . Accessed 27 Feb 2026. Tables Table 1 Experimental conditions in the factorial experiment Experimental condition SchoolHealth - Implementation elements 1. Audit and feedback+ 2. Ongoing consultation 3. Active dissemination 1 Yes Yes Yes 2 Yes Yes No 3 Yes No Yes 4 Yes No No 5 No Yes Yes 6 No Yes No 7 No No Yes 8 No No No Table 2 Specification of Dissemination & Implementation Strategies (D&I strategies) D&I strategies Actor(s) Actions Action targets Dose Timing Audit and feedback+ School nurses, teachers, students - School nurses/teachers administer digital health information forms to students before consultations - Individual and group-level feedback reports about students' health, life, well-being, and needs are provided to nurses' digital feedback and administration platform (DFA). The feedback provides nurses with decision support for health consultations and collaboration with schools - After consultations, the students report on user satisfaction and content of consultations, including user involvement and alliance with the school nurse - Group feedback reports are provided in the DFA platform - Increase nurses’ capability, opportunity, and motivation to adhere to guidelines for consultations and collaboration with schools - Increase nurses’ self-efficacy toward consultations - Increase students' involvement in and satisfaction with consultations - Identify student needs in line with guidelines - Identify school collaboration needs in line with guidelines* - Nudge student follow-up in line with guidelines The health information form is administered to all students in a class for one hour In the guideline, the consultation is estimated to take 30 min. Use of DFA is ongoing Health information forms are administered once early in the school semester. Consultations with students are carried out throughout the semester. DFA is ongoing and available for nurses throughout the school year Ongoing consultation Professional school health supervisors in the research team, school nurses - e-learning module with theory and instructional videos about effective health-promoting consultations following guidelines. - Hybrid format training and consultation in conducting 8th -grade consultations in line with guidelines - Modelled after the Reflexive teams approach - Increase nurses’ capability, opportunity, and motivation to adhere to guidelines for 8th -grade consultations - Increase nurses’ self-efficacy toward 8th -grade consultations - Provide a space for case reflections, problem-solving, and collegial support 3x180 minutes, 1x60 minutes, six e-learning videos of 7–17 minutes, e-learning approx. 60 minutes reading time Early in the semester, mid-semester, late semester, and a closing recap and reflection session after the semester Active dissemination Research staff disseminates material. Schools and school health services are encouraged to plan and conduct interprofessional collaboration meetings - Disseminate digital educational and organizational materials that can be used by school personnel and health nurses to plan and organize collaboration - The materials comprise four short videos and reflective questions that target different topics important for interprofessional collaboration - A final meeting to exchange experiences and plan further collaboration - Improve and structure interprofessional collaboration* - Provide a space to reflect together on common goals and work* - Gain better knowledge about each other’s guidelines and responsibilities* - Ensure that the school and school health services know about each other’s work* - Collaborate on individual and system levels* - Prevent silo-mentality - Plan shared work The material encourages 5 x 60-minute collaboration meetings, carried out by each school and its school health service. Four videos of about 15 minutes Dissemination at the start of the school year, and five meetings spread out across the school year are encouraged * Several action targets are related to another part of the new national guideline with recommendations about interprofessional collaboration. This reflects the SchoolHealth bundled strategy, which is designed to facilitate the implementation of recommendations regarding both the 8th -grade consultation and interprofessional collaboration. The current study, however, focuses on the results about the implementation of recommendations for the 8th -grade consultation. Table 3: Fidelity constructs and their possible scale ranges Fidelity constructs Students School nurses Scale range Scale range Adherence Total adherence 0-10 0-11 Adherence to physical assessments 0-2 3 Adherence to themes 0-8 0-8 Quality Tailoring 0-12 0-12 Quality in adherence 0-20 0-20 Alliance 0-12 NA Table 4 Participant characteristics and description of Fidelity, by D&I strategy Audit and feedback+ Ongoing consultation Active dissemination Yes No Yes No Yes No Overall Gender n = 804 n = 619 n = 741 n = 682 n = 793 n = 630 n = 1423 Boy 394 (49.0%) 310 (50.1%) 378 (51.0%) 326 (47.8%) 392 (49.4%) 312 (49.5%) 704 (49.5%) Girl 408 (50.7%) 307 (49.6%) 361 (48.7%) 354 (51.9%) 398 (50.2%) 317 (50.3%) 715 (50.2%) Neither 2 (0.2%) 2 (0.3%) 2 (0.3%) 2 (0.3%) 3 (0.4%) 1 (0.2%) 4 (0.3%) Home language n = 801 n = 605 n = 740 n = 666 n = 782 n = 624 n = 1406 Norwegian 667 (83.3%) 525 (86.8%) 600 (81.1%) 592 (88.9%) 647 (82.7%) 545 (87.3%) 1192 (84.8%) Other 134 (16.7%) 80 (13.2%) 140 (18.9%) 74 (11.1%) 135 (17.3%) 79 (12.7%) 214 (15.2%) Self-perceived family economy n = 779 n = 603 n = 714 n = 667 n = 767 n = 614 n = 1381 Worse than others 26 (3.3%) 29 (4.8%) 22 (3.1%) 33 (4.9%) 31 (4.0%) 24 (3.9%) 55 (4.0%) About the same as others 550 (70.6%) 416 (69.0%) 512 (71.7%) 454 (68.1%) 537 (70.0%) 429 (69.9%) 966 (69.9%) Better than others 202 (25.9%) 158 (26.2%) 180 (25.2%) 180 (27.0%) 199 (26.0%) 161 (26.2%) 360 (26.1%) Living situation n = 801 n = 605 n = 740 n = 666 n = 782 n = 624 n = 1406 Live with both parents 559 (69.8%) 430 (71.1%) 512 (69.2%) 477 (71.6%) 537 (68.7%) 452 (72.4%) 989 (70.3%) Other living arrangement 242 (30.2%) 175 (28.9%) 228 (30.8%) 189 (28.4%) 244 (31.2%) 172 (27.6%) 417 (29.7%) School nurse responses (range) n = 800 n = 617 n = 735 n = 682 n = 792 n = 625 n = 1417 Adherence total (0–11) 7.85 (2.01) 9.30 (1.07) 8.31 (1.89) 8.67 (1.71) 8.35 (1.84) 8.66 (1.78) 8.48 (1.82) Adherence, themes (0–8) 5.73 (1.77) 7.25 (0.87) 6.23 (1.78) 6.57 (1.44) 6.28 (1.69) 6.52 (1.56) 6.39 (1.64) Tailoring (0–12) 8.26 (1.49) 8.08 (1.70) 8.14 (1.48) 8.22 (1.69) 8.11 (1.68) 8.28 (1.46) 8.18 (1.59) Quality in adherence (0–20) 13.47 (2.12) 13.33 (2.12) 13.44 (2.12) 13.37 (2.12) 13.44 (2.22) 13.36 (1.99) 13.41 (2.12) Mean (SD) consultation duration (minutes) 31.24 (11.98) 29.41 (12.28) 29.60 (10.54) 31.36 (13.60) 30.45 (11.16) 30.44 (13.29) 30.44 (12.14) Student responses (range) n = 797 n = 603 n = 731 n = 669 n = 773 n = 627 n = 1400 Adherence total (0–10) 6.61 (1.87) 7.79 (1.93) 7.02 (2.05) 7.23 (1.90) 7.13 (1.89) 7.10 (2.09) 7.12 (1.98) Adherence, themes (0–8) 4.71 (1.77) 5.85 (1.88) 5.09 (1.98) 5.32 (1.80) 5.22 (1.83) 5.18 (1.99) 5.20 (1.90) Tailoring (0–12) 7.83 (2.23) 7.54 (2.24) 7.74 (2.30) 7.67 (2.17) 7.87 (2.25) 7.87 (2.21) 7.71 (2.24) Quality in adherence (0–20) 15.33 (2.95) 14.99 (2.98) 15.33 (2.99) 15.13 (2.96) 15.39 (3.00) 14.93 (2.97) 15.19 (2.97) Alliance (0–12) 10.35 (1.78) 10.14 (1.87) 10.32 (1.81) 10.20 (1.83) 10.34 (1.83) 10.17 (1.80) 10.26 (1.82) Table 5 Effect of the of the Dissemination & Implementation Strategies on fidelity to the guideline, reported by School health nurses. Estimate Lower Upper p Estimate Low Upper p Total adherence Adherence to themes Audit and feedback+ -1.20 -1.98 -0.41 .004 -1.32 -1.98 -0.67 < .001 Ongoing consultation -0.38 -1.17 0.40 .330 -0.36 -1.02 0.30 .275 Active dissemination 0.05 -0.74 0.83 .906 0.09 -0.57 0.74 .792 Audit and feedback+* Active dissemination 0.21 -0.58 1.00 .593 0.06 -0.60 0.72 .853 Audit and feedback+* Ongoing consultation -0.21 -0.99 0.58 .600 -0.22 -0.87 0.44 .513 Ongoing consultation * Active dissemination 0.00 -0.79 0.78 .995 -0.15 -0.80 0.51 .656 Audit and feedback+* Ongoing consultation* Active dissemination -0.32 -1.10 0.47 .424 -0.28 -0.94 0.37 .393 Tailoring Quality in adherence Audit and feedback+ 0.24 -0.48 0.97 .499 0.02 -0.86 0.90 .968 Ongoing consultation -0.14 -0.86 0.58 .702 -0.09 -0.97 0.79 .835 Active dissemination -0.04 -0.76 0.68 .910 0.16 -0.72 1.04 .717 Audit and feedback+* Active dissemination 0.37 -0.35 1.09 .307 0.35 -0.53 1.23 .432 Audit and feedback+* Ongoing consultation -0.12 -0.85 0.60 .731 0.02 -0.86 0.90 .965 Ongoing consultation * Active dissemination -0.11 -0.83 0.61 .763 0.05 -0.83 0.93 .912 Audit and feedback+* Ongoing consultation* Active dissemination -0.28 -1.00 0.44 .434 -0.60 -1.48 0.28 .176 Consultation Time (minutes) Audit and feedback+ 1.01 -3.95 5.97 .685 Ongoing consultation -1.59 -6.54 3.37 .523 Active dissemination 0.77 -4.18 5.73 .755 Audit and feedback+* Active dissemination 1.10 -3.85 6.06 .656 Audit and feedback+* Ongoing consultation 0.79 -4.17 5.74 .752 Ongoing consultation * Active dissemination -3.01 -7.97 1.95 .228 Audit and feedback+* Ongoing consultation* Active dissemination -3.98 -8.94 0.98 .112 Intraclass Correlation Coefficients: Adherence total = 0.649, Adherence to themes = 0.599, Tailoring = 0.556, Quality in Adherence = 0.468, Consultation Time = 0.480 Table 6 Effect of the Dissemination & Implementation Strategies on fidelity to the guideline, reported by student. Estimate Lower Upper p Estimate Lower Upper p Total adherence Adherence to themes Audit and feedback+ -1.26 -1.84 -0.68 < .001 -1.22 -1.76 -0.68 < .001 Ongoing consultation -0.27 -0.86 0.31 .353 -0.28 -0.82 0.26 .308 Active dissemination 0.26 -0.33 0.84 .384 0.25 -0.29 0.79 .353 Audit and feedback+* Active dissemination 0.14 -0.44 0.72 .632 0.09 -0.45 0.63 .732 Audit and feedback+* Ongoing consultation -0.37 -0.96 0.21 .204 -0.31 -0.85 0.23 .254 Ongoing consultation * Active dissemination -0.37 -0.96 0.21 .207 -0.42 -0.96 0.12 .123 Audit and feedback+* Ongoing consultation* Active dissemination 0.19 -0.39 0.78 .509 0.15 -0.39 0.69 .575 Tailoring Quality in adherence Audit and feedback+ 0.20 -0.22 0.63 .337 0.25 -0.31 0.80 .376 Ongoing consultation 0.03 -0.39 0.46 .873 0.12 -0.43 0.67 .662 Active dissemination 0.39 -0.03 0.81 .069 0.46 -0.10 1.01 .103 Audit and feedback+* Active dissemination -0.04 -0.47 0.38 .835 0.14 -0.42 0.69 .620 Audit and feedback+* Ongoing consultation -0.10 -0.53 0.32 .622 -0.32 -0.87 0.24 .257 Ongoing consultation * Active dissemination -0.44 -0.86 -0.02 .041 -0.71 -1.26 -0.16 .013 Audit and feedback+* Ongoing consultation* Active dissemination 0.01 -0.41 0.43 .963 0.01 -0.54 0.57 .957 Alliance Audit and feedback+ 0.17 -0.16 0.51 .305 Ongoing consultation 0.14 -0.20 0.47 .419 Active dissemination 0.10 -0.23 0.44 .536 Audit and feedback+* Active dissemination -0.15 -0.48 0.19 .382 Audit and feedback+* Ongoing consultation 0.05 -0.28 0.39 .748 Ongoing consultation * Active dissemination -0.35 -0.69 -0.01 .042 Audit and feedback+* Ongoing consultation* Active dissemination -0.15 -0.48 0.19 .387 Intraclass Correlation Coefficients: Adherence total: 0.266, Adherence to themes: 0.247, Tailoring: 0.075, Quality in adherence: 0.073, Alliance: 0.071 Additional Declarations No competing interests reported. Supplementary Files Appendix1.docx Appendix 1: Implementers’ fidelity to dissemination and implementation strategies Appendix2.docx Appendix 2: Items covering fidelity to guideline recommendations reported by both school nurses and students Appendix3.docx Appendix 3: Randomizing Script in R Appendix4.docx Appendix 4: Effect coding matrix Appendix5.docx Appendix 5: Engagement in implementation strategies across conditions Appendix6.docx Appendix 6: Description of fidelity by experimental group reported by students (a) and school nurses (b). 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9198555","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":620747488,"identity":"286bdfa6-7132-4b97-85d5-c5e4ee403d47","order_by":0,"name":"Åse Sagatun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYNCDDwwMCSQoZ2NgYJxBshZmHmK08Lcff/iA4Y+dXf/8HrPHtnsY8gxuN7A9+IBHi8SZHGMDxrbk5BnHeMyNc54xFBvcOcBuOAOfNQdy2CQYG5iTGY7xmEnnHPifuOFGAps0Dx4d8uefP//B8Kc+WR6kxeIAA2EtBjcSzIBeP2xnANLCQIwWwxtvjCUS244nGB5LK5PsOcBQLHnnYJskPr/InU9/+OHDn2p7ucOHt0n8OMCQx3e7+ZgEvhADgwQGhsQGOA8YGoQ0gIE9gilBlIZRMApGwSgYQQAA3gdMRCAC4wUAAAAASUVORK5CYII=","orcid":"","institution":"Center for Child and Adolescent Mental Health, Eastern and Southern Norway","correspondingAuthor":true,"prefix":"","firstName":"Åse","middleName":"","lastName":"Sagatun","suffix":""},{"id":620747489,"identity":"7a768257-433e-4fd8-90e5-bc72b09232c1","order_by":1,"name":"Malene Brekke","email":"","orcid":"","institution":"Center for Child and Adolescent Mental Health, Eastern and Southern Norway","correspondingAuthor":false,"prefix":"","firstName":"Malene","middleName":"","lastName":"Brekke","suffix":""},{"id":620747490,"identity":"ba536240-1aad-4e12-b66a-3da7d6bfcbe6","order_by":2,"name":"Carina Lisøy","email":"","orcid":"","institution":"Center for Child and Adolescent Mental Health, Eastern and Southern Norway","correspondingAuthor":false,"prefix":"","firstName":"Carina","middleName":"","lastName":"Lisøy","suffix":""},{"id":620747491,"identity":"12357d72-9a78-451a-87b0-c055c15fb040","order_by":3,"name":"Tore Wentzel-Larsen","email":"","orcid":"","institution":"Center for Child and Adolescent Mental Health, Eastern and Southern Norway","correspondingAuthor":false,"prefix":"","firstName":"Tore","middleName":"","lastName":"Wentzel-Larsen","suffix":""},{"id":620747493,"identity":"6e4b27e2-79ae-4c49-bfe6-0eb1dc01a1be","order_by":4,"name":"Kristin Sofie Waldum-Grevbo","email":"","orcid":"","institution":"Center for Child and Adolescent Mental Health, Eastern and Southern Norway","correspondingAuthor":false,"prefix":"","firstName":"Kristin","middleName":"Sofie","lastName":"Waldum-Grevbo","suffix":""},{"id":620747494,"identity":"05a231cf-4b82-4904-8ae5-fca858e3c300","order_by":5,"name":"Solveig Holen","email":"","orcid":"","institution":"Center for Child and Adolescent Mental Health, Eastern and Southern Norway","correspondingAuthor":false,"prefix":"","firstName":"Solveig","middleName":"","lastName":"Holen","suffix":""},{"id":620747495,"identity":"c7160925-9003-4a34-93b0-4c18954570eb","order_by":6,"name":"Anne Liv Askeland","email":"","orcid":"","institution":"Center for Child and Adolescent Mental Health, Eastern and Southern Norway","correspondingAuthor":false,"prefix":"","firstName":"Anne","middleName":"Liv","lastName":"Askeland","suffix":""},{"id":620747497,"identity":"649d4b2a-ce82-4454-bd0c-182d698a997f","order_by":7,"name":"Hege Sjølie","email":"","orcid":"","institution":"University College of Correctional Studies","correspondingAuthor":false,"prefix":"","firstName":"Hege","middleName":"","lastName":"Sjølie","suffix":""},{"id":620747499,"identity":"38f9c8be-71eb-4a56-9d66-be3cf082b3c2","order_by":8,"name":"Stine M. Ekornes","email":"","orcid":"","institution":"NTNU/RKBU","correspondingAuthor":false,"prefix":"","firstName":"Stine","middleName":"M.","lastName":"Ekornes","suffix":""},{"id":620747500,"identity":"3f7adc5a-280f-4d21-8797-c93f1e8272bc","order_by":9,"name":"Thomas Engell","email":"","orcid":"","institution":"Center for Child and Adolescent Mental Health, Eastern and Southern Norway","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Engell","suffix":""}],"badges":[],"createdAt":"2026-03-23 09:40:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9198555/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9198555/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106981938,"identity":"46b219b1-1314-4afc-a45b-a04ba97a3d4f","added_by":"auto","created_at":"2026-04-15 12:04:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":281709,"visible":true,"origin":"","legend":"\u003cp\u003eLogic model that shows the theorized relationships between the guideline recommendations, D\u0026amp;I-strategies, implementation determinants, and outcomes (full model for the whole study, see protocol (15)).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9198555/v1/e8f64758932d96cc3ce3e189.png"},{"id":106981939,"identity":"bba831f5-51c7-407d-96e4-30a14501de81","added_by":"auto","created_at":"2026-04-15 12:04:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":249659,"visible":true,"origin":"","legend":"\u003cp\u003eFlow-chart of the participants in the study\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9198555/v1/69c21819153bd82cb2088fa9.png"},{"id":107483373,"identity":"73c1aae0-2325-42db-91ee-8bb7a9d4b0d1","added_by":"auto","created_at":"2026-04-22 02:27:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1677087,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9198555/v1/a3020c21-33bd-41e0-956f-461a7427290a.pdf"},{"id":106994296,"identity":"f49723a3-75d5-4803-82a4-fddebff4f36d","added_by":"auto","created_at":"2026-04-15 15:07:25","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":31847,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix 1: Implementers’ fidelity to dissemination and implementation strategies\u003c/p\u003e","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-9198555/v1/0e1235c6519e70f2d8da691b.docx"},{"id":106994190,"identity":"451c3c35-11cc-41d3-a7d1-dae8f7ebfb0a","added_by":"auto","created_at":"2026-04-15 15:06:08","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":31501,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix 2: Items covering fidelity to guideline recommendations reported by both school nurses and students\u003c/p\u003e","description":"","filename":"Appendix2.docx","url":"https://assets-eu.researchsquare.com/files/rs-9198555/v1/751127b080c219806cdba527.docx"},{"id":106994233,"identity":"0890934b-108b-4067-8830-f6c5a75956e6","added_by":"auto","created_at":"2026-04-15 15:06:38","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":87535,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix 3: Randomizing Script in R\u003c/p\u003e","description":"","filename":"Appendix3.docx","url":"https://assets-eu.researchsquare.com/files/rs-9198555/v1/8dc0bfccf4078eeeceb52e11.docx"},{"id":106981942,"identity":"daa18c63-4742-4f4a-a098-68face0d2d34","added_by":"auto","created_at":"2026-04-15 12:04:08","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":28637,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix 4: Effect coding matrix\u003c/p\u003e","description":"","filename":"Appendix4.docx","url":"https://assets-eu.researchsquare.com/files/rs-9198555/v1/a324a012810f9d238562302e.docx"},{"id":107480595,"identity":"87fd0888-e3b6-4bdf-b05d-e7bbe812ed02","added_by":"auto","created_at":"2026-04-22 02:12:20","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":37709,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix 5: Engagement in implementation strategies across conditions\u003c/p\u003e","description":"","filename":"Appendix5.docx","url":"https://assets-eu.researchsquare.com/files/rs-9198555/v1/9b5b9073e4d4da17b8469afa.docx"},{"id":106981944,"identity":"e02aaafa-af32-4d50-96ea-a5b7b7180649","added_by":"auto","created_at":"2026-04-15 12:04:08","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":30622,"visible":true,"origin":"","legend":"\u003cp\u003eAppendix 6: Description of fidelity by experimental group reported by students (a) and school nurses (b).\u003c/p\u003e","description":"","filename":"Appendix6.docx","url":"https://assets-eu.researchsquare.com/files/rs-9198555/v1/2f1d52f4ac7cfa9bafa3bfdf.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Disentangling the effects of strategies for guideline implementation in school health services: A hybrid type 2 cluster-randomized factorial trial","fulltext":[{"header":"Contributions to the Literature","content":"\u003cp\u003e\u0026bull; Implementation strategies are often delivered as multi-component \u0026ldquo;packages,\u0026rdquo; but the added value of combining strategies is rarely tested using rigorous experimental designs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026bull;\u003c/strong\u003e This study applies a factorial trial to disentangle three commonly used dissemination and implementation strategies and examine their individual and combined effects.\u003c/p\u003e\n\u003cp\u003e\u0026bull; The findings challenge the assumption that more support automatically leads to better guideline fidelity and highlight that some strategies may shift provider priorities rather than uniformly improve practice.\u003c/p\u003e\n\u003cp\u003e\u0026bull; The study underscores the importance of parsimony and mechanism-focused evaluation when designing and optimizing implementation strategies.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eBest-practice guidelines intend to support decision-making in health and welfare services. Their overarching aims are to improve service quality and equity (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Best-practice guidelines that are evidence-based are developed through rigorous processes of systematically reviewing and appraising relevant research, contextualizing evidence, and co-creation among selected content area experts such as researchers, health professionals, representatives of service recipients, and advocates (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) These processes are designed to ensure guidelines are effective, safe, contextually relevant, and equitable. Despite the considerable investments made into developing and disseminating evidence-based guidelines, translating guidelines into actionable improvements and behavior change in services remains a critical hurdle across health sectors (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The dissemination of guidelines to target audiences is often the only implementation strategy employed, although it is widely considered a necessary, but insufficient, strategy for effective and sustained implementation (\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Consequently, the guidelines' impact on service delivery is limited by ineffective or lacking implementation strategies.\u003c/p\u003e\u003cp\u003eThe effort put into developing the guidelines is rarely matched by similar efforts to develop recommendations for implementing them (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A systematic umbrella review of the literature indicates that (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) a variety of bundles of different dissemination and implementation strategies can improve the implementation of guidelines, and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) the comparative effectiveness between different strategies is largely unknown (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Other comprehensive systematic reviews on implementation strategies in general (i.e., not limited to guidelines as the implementation object) come to similar conclusions (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Additionally, implementation strategies tend to be evaluated as multifaceted packages (i.e., bundles and blends of discrete strategies), and how individual strategies and different combinations contribute to effectiveness is uncertain (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Thus, research testing the effectiveness, mechanisms, and interactions of common combinations of implementation strategies is called for to inform the design of effective and efficient dissemination and implementation strategies (\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In the current study (the GuideMe trial) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), a blended implementation strategy was co-created to implement recommendations in a new national guideline for school health services. Subsequently, the strategy was disentangled into its most meaningful discrete parts and tested in all possible combinations through a factorial trial.\u003c/p\u003e\u003cp\u003e\u003cb\u003e National Guideline for Health-Promoting Consultations in School Health Services\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe school health service is a free-of-charge health service available for children and adolescents in Norwegian schools. School nurses working within this service operate at individual, group, and universal levels, providing services such as individual consultations on health and well-being and classroom health literacy teaching (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). In 2017, the Norwegian Directorate of Health disseminated a new national guideline for school health services (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The guideline serves as a professional standard, and any service choosing to deviate from this standard is expected to document and justify the decision. The guideline strongly recommends that school nurses offer individual, health-promoting consultations to all 8th -grade students. These consultations aim to strengthen students\u0026rsquo; life skills, provide an overview of the student population, identify those in need of follow-up, and actively engage students in the process. However, the guideline does not provide recommendations regarding its implementation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe SchoolHealth implementation strategy and its disentanglement\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSchoolHealth is a co-created, blended implementation strategy designed to support and promote the use of the new national guideline by school nurses with fidelity (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Using a framework for disentangling implementation strategies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), SchoolHealth was decomposed into what we considered to be its three most discrete meaningful parts (i.e., implementation elements). Discrete parts, or sets of parts, are considered meaningful elements of implementation when they do not, in theory, necessarily rely on other parts to compose a whole that can influence implementation determinants and outcomes (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Thus, meaningful implementation elements, such as discrete strategies, have a defined or assumed functional or mechanistic relationship with relevant implementation determinants and/or outcomes.\u003c/p\u003e\u003cp\u003eTwo of the disentangled elements in SchoolHealth were defined as implementation strategies, while one element was defined as a dissemination strategy. The implementation strategies were (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) an audit and feedback system with a digital administration and dialogue tool (Audit and feedback+), and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) ongoing external consultation with e-learning preparations (Ongoing consultation). The dissemination strategy (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) included dissemination of educational videos and materials to support collaboration between school nurses and school personnel in line with guideline recommendations (Active dissemination) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eThe current study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe objective of the study was to advance scientific knowledge about the effectiveness and mechanisms of strategies commonly used to disseminate and implement guidelines in primary healthcare and school settings. The GuideMe trial was designed to optimize strategies for implementing recommendations in the new national guideline by investigating the effectiveness and interactions of the discrete elements that make up the blended SchoolHealth strategy. We tested the individual and interactional effects of three dissemination and implementation strategies (D\u0026amp;I-strategies) on fidelity to the guideline recommendation for conducting health consultations with all 8th -grade students.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe conducted a hybrid type 2 cluster-randomized factorial trial within the school health service, and this paper presents results from the implementation part of the hybrid trial. As each of the \u003cem\u003ethree\u003c/em\u003e discrete D\u0026amp;I-strategies in SchoolHealth had two levels (yes/no, 2ᵏ) there were eight (2x2x2) possible experimental conditions (see Table 1). The design enables assessment of each individual factor\u0026rsquo;s performance (i.e., main effects), as well as examination of whether the factors interact to influence outcomes (i.e., interaction effects) (19). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFigure 1 depicts theorized relationships between the guideline recommendation, D\u0026amp;I-strategies, implementation determinants, and outcomes. The content, actors, and aims for each strategy are specified in Table 2. The Exploration, Preparation and Implementation framework (EPIS) (20) was used to guide the implementation process, while EPIS and the Capability, Opportunity, Motivation \u0026ndash; Behavior theory (COM-B) (21) informed tailoring of strategies, development of a theoretical model, and measurement of determinants and outcomes. Complete details about the theoretical foundations and development of the GuideMe trial can be found in the protocol (16).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInsert Figure 1 here -\u003c/p\u003e\n\u003cp\u003eFigure 1: Logic model that shows the theorized relationships between the guideline recommendations, D\u0026amp;I-strategies, implementation determinants, and outcomes (full model for the whole study, see protocol (16)).\u003c/p\u003e\n\u003cp\u003eInsert Table 2 here -\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Specification of Implementation and Dissemination Strategies (D\u0026amp;I strategies)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted in Norwegian lower-secondary public schools and school health services. Norway\u0026apos;s school system is predominantly public, with the first ten years of education being mandatory. The school health service is part of the primary municipal health care services and aims to promote good health and prevent disease (17, 18).\u0026nbsp;The Norwegian Directorate of Health has estimated a staffing norm for the school health service, which for lower secondary schools corresponds to one full-time school nurse per approximately 330 students. Staffing levels of school nurses in Norwegian schools vary across municipalities (22). In this sample, about 45% of schools had a school nurse at or above the recommended norm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterventions: Guideline recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe national guideline for the school health service strongly recommends an 8\u003csup\u003eth\u003c/sup\u003e-grade health consultation with all students, and outlines goals (see introduction) and content for the consultations. During the consultation, the school nurses are to inspect postural assessment (scoliosis evaluation), measure weight and height, and address themes in the following categories: Coping, well-being, and relationships; sleep and sleep habits; diet and meals; physical activity, leisure activities, and sedentary behavior; dental health; sexual health; tobacco, alcohol, and other substance use; violence, abuse, and neglect; and provide information about the general practitioner scheme. The guideline further states that consultations should strengthen user involvement in the consultation and be based on students\u0026rsquo; needs and preferences. The consultation is estimated to last approximately 30 minutes (18).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDissemination and implementation strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe three SchoolHealth D\u0026amp;I-strategies tested as factors in the trial (16) were:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAudit and feedback+ (\u003c/em\u003e\u003cem\u003eA\u0026amp;F\u003c/em\u003e\u003cem\u003e)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBefore the 8\u003csup\u003eth\u003c/sup\u003e-grade consultation, students completed a digital health form covering themes to be addressed in the consultation, which generated a color-coded individualized \u003cem\u003efeedback report\u003c/em\u003e for the school nurse. \u003cem\u003eThe feedback report\u003c/em\u003e intended to provide school nurses with an overview of the students\u0026rsquo; health and well-being and help tailor the consultation to the students\u0026rsquo; needs and preferences. After the consultation, both students and school nurses evaluated fidelity to the guideline and user satisfaction via digital questionnaires, producing \u003cem\u003ea consultation report\u003c/em\u003e and a \u003cem\u003euser satisfaction report\u003c/em\u003e. These, along with an \u003cem\u003eaggregated school report\u003c/em\u003e based on students\u0026rsquo; health forms, were available to school nurses and service leaders through the A\u0026amp;F platform (16).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOngoing consultation\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOngoing consultation aimed to strengthen school nurses\u0026rsquo; motivation and capabilities to follow the 8\u003csup\u003eth\u003c/sup\u003e-grade consultation guidelines. It included an e-learning module covering theory and instructional videos, a series of three digital or hybrid group consultations based on a reflexive team approach (23), and one wrap-up session. Each group consultation involved 5\u0026ndash;7 school nurses and lasted about 2.5 hours (16).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eActive dissemination\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Active dissemination strategy (i.e., planned, targeted, and proactive effort to spread and promote the use of innovations (24), provided web-based resources to support interprofessional collaboration between schools and the school health service. The materials encourage regular collaboration meetings throughout the school year, beginning with the first of the four sessions at the start of the school year. Participants were encouraged to view the instructional videos and to work together on shared tasks in the meetings (16). This strategy was not designed to influence fidelity to guideline recommendations for the 8\u003csup\u003eth\u003c/sup\u003e-grade consultations directly. Instead, it was designed to promote interprofessional collaboration, which is another recommendation in the new national guideline that will be addressed in a separate publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith the three D\u0026amp;I-strategies serving as experimental factors, participants received condition-specific information and introductory training relevant to their allocated condition. All participants also attended a kick-off meeting where they received standardized information about the new national guideline and recommendations, and training in the electronic data collection system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and Location\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study gathered data from 8\u003csup\u003eth\u003c/sup\u003e-grade students and school nurses in southeastern and central Norway, encompassing both rural and urban areas. The participating schools had between one and four parallel 8\u003csup\u003eth\u003c/sup\u003e-grade classes. In Norway, 8\u003csup\u003eth\u003c/sup\u003e-graders are generally 12 to 13 years old. Data collection spanned two school years (2022/23 and 2023/24), with each school participating for one year. Two-thirds of the municipalities participated in the final school year.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBackground of participants\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudents and school nurses responded to questions about several background variables at the beginning of the school semester (T1). Students reported their home language, perceived family economic status, and living arrangement (e.g., with both parents or otherwise). The student\u0026rsquo;s gender was registered by the parents during the consenting process (boys, girls, or neither). School nurses stated their age and years of professional experience.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eImplementers\u0026rsquo; fidelity to dissemination and implementation strategies\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe applied a combination of monitoring and post-measures to assess implementers\u0026rsquo; fidelity to the components of the D\u0026amp;I strategies. For each condition, research coordinators monitored adherence to implementation plans (structure, content, dosage, absenteeism), coded adaptations as fidelity consistent or inconsistent, registered details about technical assistance provided, and registered unexpected events and circumstances that may affect fidelity (i.e., emergent events). A simplified version of The Framework for Reporting Adaptations and Modifications to Implementation Strategies (FRAME-IS) (25) was used for coding and judging adaptations and emergent events. Research staff and supervisors self-reported on adherence, quality, and adaptations in delivering training and supervision (see Appendix 1). An implementation specialist (TE) reviewed all monitoring and coding and clarified questions and details with coordinators or research staff. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSchool nurses\u0026rsquo; engagement in dissemination and implementation strategies\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSchool nurses responded to post-measures (at the end of the school year, T3) about their engagement with different components within the three D\u0026amp;I strategies. Complete details about implementation fidelity and engagement measurements are available in the study protocol (16).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFidelity to guideline recommendations\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e(Adherence, Quality, Duration)\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFidelity to the guideline was evaluated by assessing school nurses\u0026rsquo; \u003cem\u003eadherence\u0026nbsp;\u003c/em\u003eto the recommendations for 8\u003csup\u003eth\u003c/sup\u003e-grade consultations, the \u003cem\u003equality\u0026nbsp;\u003c/em\u003ewith which these recommendations were implemented, and the \u003cem\u003eduration\u003c/em\u003e of each consultation. Complete details on the conceptualization and measurement of guideline fidelity are available in the protocol (16). Fidelity was measured using self-reports from school nurses and corresponding reports from students, both collected immediately after each consultation (T2). The scale-ranges for these fidelity measures are presented per informant type in Table 3, and a description of the items covering the measures is provided in Appendix 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdherence\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTotal adherence\u003c/em\u003e to guideline recommendations was assessed using checklist items covering key recommendations (see Appendix 2 for coding details). This included items on measuring height and weight, and a postural assessment (\u003cem\u003eAdherence to physical assessments\u003c/em\u003e), and whether the eight main conversational themes recommended to be covered were addressed during the consultation \u003cem\u003e(Adherence to themes\u003c/em\u003e). All items were self-developed and were user-tested for relevance and clarity by both students and school nurses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eQuality\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe\u003cem\u003e\u0026nbsp;Quality\u003c/em\u003e of how the recommendations were addressed was measured through school nurses\u0026rsquo; and students\u0026rsquo; reflections on \u003cem\u003eQ\u003c/em\u003e\u003cem\u003euality in adherence\u003c/em\u003e and \u003cem\u003eT\u003c/em\u003e\u003cem\u003eailoring\u003c/em\u003e of the consultation, as well as students\u0026rsquo; perceived \u003cem\u003eA\u003c/em\u003e\u003cem\u003elliance\u003c/em\u003e with the school nurse. The items were adapted from user experience measures previously applied in Norwegian health services (26, 27), and based on the national guideline (18). All items were rated on a 5-point scale (from 0-4). \u003cem\u003eQuality in adherence\u0026nbsp;\u003c/em\u003eassessed whether the conversation facilitated a health-promoting dialogue. Specifically, they assessed the extent to which tailored health information was provided, whether positive habits were acknowledged, and whether the nurse actively listened to the student. Additionally, the items evaluated the extent to which the student gained insight into healthy behaviors and perceived the consultation as a safe and supportive experience. \u003cem\u003eTailoring\u003c/em\u003e assessed whether the school nurse centered the conversation on what mattered to the student, acknowledged positive habits, and provided tailored health information. Students responded to additional items about their perceptions of \u003cem\u003eAlliance\u0026nbsp;\u003c/em\u003ewith the school nurse as an indicator of quality in school nurses\u0026rsquo; use of guidelines (the items are reported in Appendix 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDuration\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSchool nurses reported the time spent on student consultations (\u003cem\u003eduration\u003c/em\u003e) immediately after each consultation (in minutes) (T2). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe used the R-package MOST (28) for sample size estimation. We assumed a two-sided 5% alpha-level, an effect size of d = 0.30, and statistical power of 0.80 (\u0026beta; = 0.20). As data was hierarchical, we accounted for an intraclass correlation coefficient (ICC) of 0.05 and assumed an average cluster size of 30 (SD = 15) (29). In 2\u003cem\u003eᵏ\u003c/em\u003e factorial designs (as applied in this study), the statistical power to detect main effects and interaction effects is approximately equivalent (30). The power calculations indicated that 36 schools and 1,080 students were required for the study. To accommodate potential dropouts and the need for subgroup analyses, we aimed to recruit approximately 40 schools and 1,200 students.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnrollment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSchool health services in Southeastern and Central Norway were invited to participate in the GuideMe trial. Information meetings were held with 40 services in Southeastern and Central Norway. Of these, 26 joined the study, involving 56 school nurses and 49 schools. These represented both large and small municipalities in urban and rural areas. All students, in the classes selected by the school, were invited to participate (\u003cem\u003eN\u003c/em\u003e= 2079). Recruitment procedures are described in the study protocol paper (16). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRandomization\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe schools were randomly assigned to different combinations of the three D\u0026amp;I-strategies in SchoolHealth (16). The procedure was carried out in R using a function specifically written for the GuideMe study (see syntax in Appendix 3). The function was developed by a statistician in collaboration with key personnel in the project and was witnessed by an independent third party. The schools were randomized to one of the eight experimental conditions (see Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe used linear mixed effects models to examine the individual (main) and interaction effects of the three study factors. Separate models were estimated for each outcome using both students and school nurses as informants about the 8\u003csup\u003eth\u003c/sup\u003e-grade consultation. To account for clustered data, random effects between school\u0026nbsp;nurses were included.\u0026nbsp;The main independent variables were effect-coded variables for the three study factors and their products, as described by Kugler, Dziak \u0026amp; Trail (31). For each factor, one level was coded \u0026ndash;1 (off), and the other as 1 (on) (Effect coding matrix, see Appendix 4). Interaction terms were computed as the products of the effect-coded variables for the main effects. With effect-coding for two-level factors, multiplying the coefficients by a scaling constant of 2 yields the estimated main and interaction effects. Main effects were interpreted as the average change in the outcome variable associated with receiving a given factor compared to not receiving it, averaged across all levels of the other factors (19, 32). Two-way interaction effects were interpreted as indicating whether the effect of one factor depended on the level of another factor, averaged over the levels of the remaining factor. A three-way interaction was interpreted as the two-way interaction effect being different depending on the level of the third factor.\u003c/p\u003e\n\u003cp\u003eIn supplementary analyses, we examined interactions between the effects and sex, to explore potential differences reported by boys and girls.\u003c/p\u003e\n\u003cp\u003eAll analyses were conducted in R version 4.2.1. (The R Foundation for Statistical Computing, Vienna, Austria). Mixed effects analyses were fitted using the nlme package (33).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eDescription of the participants\u003c/h2\u003e\n \u003cp\u003eIn total, 1400 8th -grade students (67% of the invited) and 56 school nurses from 48 schools answered the questionnaire after the 8th -grade consultation. The participant flow is illustrated in Fig. \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003eInsert Fig. \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here -\u003c/p\u003e\n \u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e: Flow-chart of the participants in the study\u003c/p\u003e\n \u003cp\u003eThe number of school nurses conducting the 8th -grade consultations at each school was one (n\u0026thinsp;=\u0026thinsp;41), two (n\u0026thinsp;=\u0026thinsp;6), or three (n\u0026thinsp;=\u0026thinsp;1). The mean age of the school nurses was 43.5 years (range: 27\u0026ndash;64) and their mean professional experience was 8 years (range\u0026thinsp;\u0026lt;\u0026thinsp;1\u0026ndash;28). Among the students, 704 (49.5%) identified as boys, 715 (50.2%) as girls, and 4 (0.3%) as neither. Based on visual inspection of descriptive statistics, the students` self-perceived family economy, home language, and living arrangements appeared comparable across the D\u0026amp;I strategies (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eInsert Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e here -\u003c/p\u003e\n \u003cp\u003eTable \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e: Participant characteristics and description of Fidelity, by D\u0026amp;I strategy\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eImplementers\u0026apos; fidelity to dissemination and implementation strategies and emergent events\u003c/h2\u003e\n \u003cp\u003eImplementers\u0026rsquo; fidelity to D\u0026amp;I strategies was high for all conditions, and the large majority of adaptations were considered fidelity-consistent. Three adaptations were fidelity-inconsistent but judged to have limited impact on experimental validity (details available in Appendix 1). Seven emergent events (e.g., turnovers, crises, technical issues) may have influenced implementation fidelity (ranging from 0\u0026ndash;2 events in each condition), most notably in the condition with all three strategies/factors and the condition with active dissemination only. Requested technical assistance relevant to the experimental conditions varied. The condition with all three D\u0026amp;I strategies had 13 instances of receiving technical assistance (phone calls and emails). The active dissemination-only condition had seven such instances, and the condition with A\u0026amp;F and Ongoing consultation had five. The remaining conditions had two or fewer instances of relevant technical assistance. Complete implementation fidelity results for each strategy component in each condition are available in Appendix 1.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eSchool nurses\u0026rsquo; engagement in the Dissemination and Implementation strategies\u003c/h2\u003e\n \u003cp\u003eThe school nurses\u0026rsquo; engagement varied between implementation strategies and across components within implementation strategies; full details are provided in Appendix 5. Overall, engagement was considered moderate to high for the A\u0026amp;F strategy and the Ongoing consultation strategy, and low in the Active dissemination strategy. The A\u0026amp;F strategy consists of several reports, and most school nurses used the Individualized feedback report for both preparation and completion of the consultations with students. The majority of school nurses also used the School report and User satisfaction report, while the Consultation report was used less frequently. Concerning the Ongoing consultation strategy, most school nurses reported high engagement with the e-learning modules. However, about half did not complete the e-learning before the consultations, as planned. Participation in the consultation sessions was generally high, about 90% attended two or more of the three sessions. In contrast, the collaboration meetings in the Active dissemination strategy were held less frequently than planned. Twenty-six percent of school nurses did not attend any meetings, 26% attended one, and 33% attended three or more meetings (see details in Appendix 5).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eFidelity to the 8th -grade recommendations\u003c/h2\u003e\n \u003cp\u003eThe mean \u003cem\u003eadherence\u003c/em\u003e score, representing the number of recommended themes addressed during the 8th -grade consultation, was 6.39 as reported by school nurses and 5.20 as reported by students (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), corresponding to 80% and 65% of the maximum possible score, respectively. For the school nurses, the mean \u003cem\u003equality in adherence\u003c/em\u003e score (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) corresponded to 67% of the maximum possible score, and for students the corresponding score was 76% of maximum, indicating generally favorable perceptions of consultation quality. The mean score for tailoring the consultation to students\u0026rsquo; individual needs was equivalent to 68% and 64% as reported by school nurses and students, respectively.\u003c/p\u003e\n \u003cp\u003eOn average the 8th -grade consultations lasted for 30.2 minutes (SD\u0026thinsp;=\u0026thinsp;12.2).\u003c/p\u003e\n \u003cp\u003eThese ratings suggest an overall moderate-to-high level of perceived fidelity from both perspectives, with students reporting fewer themes covered and higher quality in the adherence to the 8th -grade consultations than school nurses.\u003c/p\u003e\n \u003cp\u003eDescription of fidelity to the 8th -grade recommendation, organized by experimental group for both students and school nurses, is presented in Appendix 6.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eEffects of the dissemination and implementation strategies\u003c/h2\u003e\n \u003cp\u003eWe found a statistically significant \u003cem\u003emain\u003c/em\u003e effect of A\u0026amp;F on both \u003cem\u003eTotal adherence\u003c/em\u003e to key recommendations, and \u003cem\u003eAdherence to themes\u003c/em\u003e, as reported by both school nurses (Table \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) and students (Table \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Specifically, school nurses using the A\u0026amp;F addressed fewer themes in the consultation compared to those who did not use this tool.\u003c/p\u003e\n \u003cp\u003eInsert Tables \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e here -\u003c/p\u003e\n \u003cp\u003eTable \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e: Effect of the of the Dissemination \u0026amp; Implementation Strategies on fidelity to the guideline, reported by School health nurses.\u003c/p\u003e\n \u003cp\u003eTable \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e: Effect of the of the Dissemination \u0026amp; Implementation Strategies on fidelity to the guideline, reported by student.\u003c/p\u003e\n \u003cp\u003eWe found no other significant main effects of the D\u0026amp;I strategies on any of the outcome measures (duration, quality, tailoring and alliance) reported by school nurses or students (Tables \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). However, a small statistically significant two-way interaction was found between Ongoing consultation \u003cem\u003eand\u003c/em\u003e Active dissemination reported by students for Quality (\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.013\u003c/em\u003e), Tailoring (\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.041\u003c/em\u003e) and Alliance (\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.042\u003c/em\u003e) (Table \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e), with the effect of each of these two factors being reduced when the other one was present, compared with when it was not present. School nurses\u0026rsquo; reports did not support this finding. Additionally, as described above, the \u003cem\u003emain\u003c/em\u003e effects of the Ongoing consultation and Active dissemination were not significant for any of the outcomes. Taken together, this isolated antagonistic interaction, observed only in student reports and in the absence of corresponding main effects, does not suggest a consistent or actionable antagonistic relationship between these two strategies.\u003c/p\u003e\n \u003cp\u003eIn supplementary analyses examining whether student-reported effects varied by sex (boys/girls), no significant interactions between effects and sex were found for \u003cem\u003eTotal Adherence\u003c/em\u003e (lowest \u003cem\u003ep\u003c/em\u003e = .226), \u003cem\u003eAdherence to themes\u003c/em\u003e (lowest \u003cem\u003ep\u003c/em\u003e = .257) or \u003cem\u003eQuality\u003c/em\u003e (lowest \u003cem\u003ep\u003c/em\u003e-value .108). For the subscale \u003cem\u003eAlliance\u003c/em\u003e, the three-way interaction differed significantly by sex (\u003cem\u003ep\u003c/em\u003e = .018), but was not statistically significant within either groups when studied separately: boys (estimate 0.09, CI [-0.30, 0.49], \u003cem\u003ep\u003c/em\u003e = .631), girls (estimate\u0026thinsp;\u0026minus;\u0026thinsp;0.37, CI [-0.75, 0.02], \u003cem\u003ep\u003c/em\u003e = .062), though a somewhat low \u003cem\u003ep\u003c/em\u003e-value for girls was noted\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis factorial trial estimated the main effects and interactions of three common dissemination and implementation strategies \u0026ndash; A\u0026amp;F, Ongoing consultation, and Active dissemination \u0026ndash; on school nurses\u0026rsquo; fidelity to guidelines for health consultations with students.\u003c/p\u003e \u003cp\u003eThe strategies produced few differential effects. The only strategy that had a statistically significant effect, compared with the average of the other two, was the A\u0026amp;F strategy\u0026rsquo;s effect on adherence to content in the consultation. School nurses using the A\u0026amp;F strategy addressed fewer themes in the consultation than those without. Overall, moderate to high fidelity to the consultation guideline was reported by both the school nurses and students across all experimental groups.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eEffects of the dissemination and implementation on fidelity to the 8th -grade consultation recommendation\u003c/h2\u003e \u003cp\u003eOur findings challenge the assumptions that A\u0026amp;F generally enhance guideline adherence (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). A likely explanation is that the individualized reports helped school nurses prioritize specific themes. These reports provided color-coded feedback summarizing scores on students\u0026rsquo; health, well-being, health literacy, and needs. The report may have nudged nurses to focus on seemingly more relevant themes while disregarding others.\u003c/p\u003e \u003cp\u003eThe findings are consistent with the clinical performance feedback intervention theory (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) suggesting that feedback interventions are most effective when they directly support actionable behaviors. The individualized report in the A\u0026amp;F platform provided immediate suggestions regarding appropriate themes to prioritize and was widely used by the school nurse both in preparation for and during student consultations. These report features align with CP-FIT theory, suggesting that actionability is the primary mechanism in such behavioral induction. This interpretation is further supported by a recent systematic review concluding that A\u0026amp;F is most effective when designed to help recipients prioritize and take action (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). This may explain why school nurses using the A\u0026amp;F platform addressed fewer topics during consultations than nurses without the platform.\u003c/p\u003e \u003cp\u003eThe guideline recommends tailoring the consultations to students\u0026rsquo; needs, but without specifying \u003cem\u003ehow\u003c/em\u003e and \u003cem\u003ewhen\u003c/em\u003e to tailor. The drift in adherence to guideline themes may therefore reflect what school nurses deem appropriate tailoring in line with recommendations. Considering the limited time available for each consultation (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30.2 minutes, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12.2), and the number of themes (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and physical assessments (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) recommended to be addressed in the consultation, feedback-informed prioritization may also have been considered necessary for the overall quality of the consultation and tailoring. However, the A\u0026amp;F strategy did not significantly affect students\u0026rsquo; or nurses\u0026rsquo; perceptions of tailoring, nor the quality or duration of the consultations. Thus, in this case, the highly actionable feedback may have led to prioritization of themes at the expense of comprehensive adherence to all themes outlined in the guideline.\u003c/p\u003e \u003cp\u003e Apart from adherence to themes, no significant main effects were observed across strategies on any of the constructs indexing guideline fidelity, including quality in the use of guideline recommendations, tailoring to students' needs, or alliance between students and nurses. Although this dismantling factorial trial was exploratory, these findings may be considered notable considering the current literature. A\u0026amp;F is widely regarded as a potent and empirically well-supported implementation strategy (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The A\u0026amp;F strategy in the current study was co-designed and tailored to include the core elements and primary mechanisms that contemporary theory posits are essential for A\u0026amp;F to exert effects (i.e., behavioral induction and alignment with identity, culture, and capacity limitations (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Consequently, stronger main effects with this strategy were perhaps expected. However, our results provide only partial support for A\u0026amp;F as a potent strategy, likely due to the actionability mechanism proposed by CP-FIT.\u003c/p\u003e \u003cp\u003eConsultation is a common element in effective implementation strategies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) and there are several potential mechanisms by which Ongoing consultation can influence fidelity to interventions and guidelines (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). The limited effects of Ongoing consultation, contrast these theories suggesting that sustained support and reflective practice are key drivers of fidelity (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). However, in this trial, nurses across conditions appeared to have baseline motivation and a supportive climate for implementing the national guideline (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). This might have reduced the effect of the Ongoing consultation strategy compared with the average of the other two.\u003c/p\u003e \u003cp\u003eThe Active dissemination strategy in the study has, in contrast to the two implementation strategies, no theoretical mechanisms directly linked to fidelity to the recommendations for the 8th -grade consultation. Still, this strategy did not affect fidelity to the 8th -grade recommendations differently than the two implementation strategies (combined). We caution against interpreting these results as \u0026ldquo;anything goes,\u0026rdquo; or as dissemination being as effective as more active implementation strategies. To our understanding, the results are more likely to be explained by methodological limitations, particularly by intervention effects arising from fidelity measurement.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eMethodological considerations\u003c/h2\u003e \u003cp\u003eAll school nurses completed fidelity assessments immediately after each consultation. These measurements may have functioned as an intervention itself. Responding to items about fidelity to guideline recommendations may have increased awareness of expected consultation content, prompted reflection, and encouraged changes in practice, regardless of experimental group. This reactive measurement effect may partly explain the moderate-to-high overall fidelity scores observed in the study, which were higher than those typically reported in a previous study in the service (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). The relatively high fidelity score across all experimental groups may also reflect that school nurses participating in the study already had strong baseline motivation and capacity to implement the guideline recommendations, and that the frequent fidelity measurements served as reminders or nudges that facilitated fidelity. Despite the methodological considerations, our findings align with reviews that highlight the uncertainty surrounding the added value of multi-component strategies (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). A\u0026amp;F remains one of the most evidence-supported implementation strategies, yet effectiveness varies by context, design, and aim (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Our results suggest that when A\u0026amp;F emphasizes prioritization, it may inadvertently compromise comprehensiveness. This may imply that guideline development should specify how guideline recommendations should and should not be tailored, with corresponding implications for the design of feedback interventions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eSeveral implications can be drawn from the results. First, relatively strong fidelity across conditions highlights school nurses as capable implementers of national guidelines. Frequent self-report audit or reminders of core guideline recommendations in this context can seemingly go a long way, while additional implementation strategies may serve more as fine-tuning supports than as essential preconditions for adoption. This has relevance for policy: investing in tailored A\u0026amp;F or reminders integrated into workflow structures, such as medical records in the health care service, may be more cost-effective than multi-component strategies that require ongoing external implementation support.\u003c/p\u003e \u003cp\u003eSecond, and relatedly, the design of A\u0026amp;F strategies, and implementation strategies in general, should be mindful of potential unintended consequences as a function of seemingly positive design features such as high actionability. User-friendly feedback systems can serve as choice architecture, automatically steering provider behavior. In the case of guidelines, A\u0026amp;F designers may consider incorporating prompts that ensure broad coverage of core guideline recommendations, while still allowing for prioritization of individual student needs.\u003c/p\u003e \u003cp\u003eThird, the absence of clear additive or synergistic effects of combining strategies suggests that efficiency and parsimony in implementation support are important. Rather than assuming more is better, future research should continue to disentangle strategies and test mechanisms (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), as recommended in implementation optimization frameworks (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) and common elements approaches (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), and also test how and when blended implementation strategies (i.e., consciously designed \u0026ldquo;packages/programs\u0026rdquo; of implementation strategies) are greater than the sum of their parts.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis trial did not find convincing evidence of differential or additive/interactional effects between A\u0026amp;F, Ongoing consultation, and Active dissemination on fidelity to guidelines. While overall fidelity to the guideline recommendations was relatively high, the Audit and Feedback+ strategy appeared to shift the balance of consultation content rather than uniformly improving fidelity. Neither Ongoing consultation nor Active dissemination produced consistent additional benefits. These findings underscore the importance not only of comparing strategies but also of understanding how and when they influence provider behavior and student experience.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eA\u0026amp;F\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAudit and Feedback+\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCOM-B\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCapability, Opportunity, Motivation \u0026ndash; Behavior theory\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eD\u0026amp;I-strategies\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDissemination and Implementation strategies\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eEPIS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Exploration, Preparation, Implementation, and Sustainment framework\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eFRAME-IS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Framework for Reporting Adaptations and Modifications to Implementation Strategies\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was reported to the Norwegian Regional Committees for Medical and Health Research Ethics for approval. They concluded that the project fell outside the scope of the Norwegian Health Research Act, cf. \u0026sect; 2, and could therefore be conducted without their approval. The study followed Norwegian procedures for ethical evaluation and was carried out in accordance with the Norwegian ethical guidelines for research (41). Data protection was assessed by Sikt \u0026ndash; The Norwegian Agency for Shared Services in Education and Research. Informed consent was obtained from all participants, and parents of 8\u003csup\u003eth\u003c/sup\u003e-grade students.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to the General Data Protection Regulation laws but may be provided by the corresponding author on reasonable request.\u0026nbsp;Any materials related to the dissemination and implementation strategies can be provided by the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was primarily funded by the Norwegian Research Council (grant number 320097). Furthermore, the participating research institutions RBUP, NTNU, and VID provided additional support, primarily through the allocation of personnel resources.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026Aring;S, TE, CL, TWL and MB drafted the manuscript with input from all authors. All authors critically revised the manuscript and approved the version submitted.\u003c/p\u003e\n\u003cp\u003e\u0026Aring;S, CL, TWL, TE and MB undertook the analyses and prepared the tables and figures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026Aring;S, SH, KWG, MB, SE and TE have been involved in the development of the implementation strategies (SchoolHealth). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026Aring;S, SH, TE, MB, KWG, HS and SE have been involved in the choice and refinement of assessments and defining mechanisms. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026Aring;S, SH, TE, HS and SE have been involved in the design of the study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026Aring;S, SH, KWG and ALA have been involved in the data collection/weekly follow-up of the study.\u003c/p\u003e\n\u003cp\u003e\u0026Aring;S is the principal investigator of the GuideMe study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our sincere gratitude to all adolescents, school nurses, leaders, and school personnel who have collaborated with us or provided invaluable feedback throughout the development of SchoolHealth and the assessments used in this study.\u003c/p\u003e\n\u003cp\u003eWe are grateful to the Research and Innovation Development Team at RBUP for their work developing the quantitative data collection platform and the technical solution in the Digital Feedback and Administration Tool.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, we wish to acknowledge Carsten Obel, who is sadly no longer with us, for his longstanding dedication to research aimed at promoting the health of young people and the services that support them. He played a key role in initiating this project, and his contributions continue to inspire our work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Health for the world\u0026rsquo;s adolescents: a second chance in the second decade. Geneva: WHO; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Institute for Health and Care Excellence (NICE). Developing NICE guidelines: the manual. 2014. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nice.org.uk/process/pmg20\u003c/span\u003e\u003cspan address=\"https://www.nice.org.uk/process/pmg20\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 27 Feb 2026.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorwegian Directorate of Health. 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Consultation as an implementation strategy for evidence-based practices across multiple contexts: unpacking the black box. Adm Policy Ment Health. 2013;40(6):439\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSagatun \u0026Aring;, Wentzel-Larsen T, Engell T. Implementation of guidelines in school health services: leadership and climate [Implementering av retningslinjer i skolehelsetjenesten: ledelse og klima]. Nor J Clin Nurs. 2026. In press.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWaldum-Grevbo KS. Public health nurse: are you following the new national recommendations? [Helses\u0026oslash;ster: f\u0026oslash;lger du de nye, nasjonale anbefalingene?] Sykepl Fag. 2018;106:70773.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuastaferro K, Collins LM. Optimization methods and implementation science: an opportunity for behavioral and biobehavioral interventions. Implement Res Pract. 2021;2:26334895211054363.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Committee for Research Ethics. General guidelines. 2019. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.forskningsetikk.no/en/guidelines/general-guidelines/\u003c/span\u003e\u003cspan address=\"https://www.forskningsetikk.no/en/guidelines/general-guidelines/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 27 Feb 2026.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":" \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eExperimental conditions in the factorial experiment\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cdiv class=\"SimplePara\"\u003eExperimental\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003econdition\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eSchoolHealth - Implementation elements\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1. Audit and feedback+\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2. Ongoing consultation\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e3. Active dissemination\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e8\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eSpecification of Dissemination \u0026amp; Implementation Strategies (D\u0026amp;I strategies)\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eD\u0026amp;I strategies\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eActor(s)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eActions\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eAction targets\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003eDose\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003eTiming\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eAudit and feedback+\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eSchool nurses, teachers, students\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e- School nurses/teachers administer digital health information forms to students before consultations\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Individual and group-level feedback reports about students' health, life, well-being, and needs are provided to nurses' digital feedback and administration platform (DFA). The feedback provides nurses with decision support for health consultations and collaboration with schools\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- After consultations, the students report on user satisfaction and content of consultations, including user involvement and alliance with the school nurse\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Group feedback reports are provided in the DFA platform\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e- Increase nurses\u0026rsquo; capability, opportunity, and motivation to adhere to guidelines for consultations and collaboration with schools\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Increase nurses\u0026rsquo; self-efficacy toward consultations\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Increase students' involvement in and satisfaction with consultations\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Identify student needs in line with guidelines\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Identify school collaboration needs in line with guidelines*\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Nudge student follow-up in line with guidelines\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003eThe health information form is administered to all students in a class for one hour\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eIn the guideline, the consultation is estimated to take 30 min. Use of DFA is ongoing\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003eHealth information forms are administered once early in the school semester. Consultations with students are carried out throughout the semester. DFA is ongoing and available for nurses throughout the school year\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eOngoing consultation\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eProfessional school health supervisors in the research team, school nurses\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e- e-learning module with theory and instructional videos about effective health-promoting consultations following guidelines.\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Hybrid format training and consultation in conducting 8th -grade consultations in line with guidelines\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Modelled after the Reflexive teams approach\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e- Increase nurses\u0026rsquo; capability, opportunity, and motivation to adhere to guidelines for 8th -grade consultations\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Increase nurses\u0026rsquo; self-efficacy toward 8th -grade consultations\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Provide a space for case reflections, problem-solving, and collegial support\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3x180 minutes, 1x60 minutes, six e-learning videos of 7\u0026ndash;17 minutes, e-learning approx. 60 minutes reading time\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003eEarly in the semester, mid-semester, late semester, and a closing recap and reflection session after the semester\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eActive dissemination\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eResearch staff disseminates material. Schools and school health services are encouraged to plan and conduct interprofessional collaboration meetings\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e- Disseminate digital educational and organizational materials that can be used by school personnel and health nurses to plan and organize collaboration\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- The materials comprise four short videos and reflective questions that target different topics important for interprofessional collaboration\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- A final meeting to exchange experiences and plan further collaboration\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e- Improve and structure interprofessional collaboration*\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Provide a space to reflect together on common goals and work*\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Gain better knowledge about each other\u0026rsquo;s guidelines and responsibilities*\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Ensure that the school and school health services know about each other\u0026rsquo;s work*\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Collaborate on individual and system levels*\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Prevent silo-mentality\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e- Plan shared work\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003eThe material encourages 5 x 60-minute collaboration meetings, carried out by each school and its school health service. Four videos of about 15 minutes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003eDissemination at the start of the school year, and five meetings spread out across the school year are encouraged\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e* Several action targets are related to another part of the new national guideline with recommendations about interprofessional collaboration. This reflects the SchoolHealth bundled strategy, which is designed to facilitate the implementation of recommendations regarding both the 8th -grade consultation and interprofessional collaboration. The current study, however, focuses on the results about the implementation of recommendations for the 8th -grade consultation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e\n\u003cp\u003eTable 3: Fidelity constructs and their possible scale ranges\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 406px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFidelity constructs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool nurses\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eScale range\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eScale range\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cem\u003eAdherence\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eTotal adherence\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0-11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eAdherence to physical assessments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eAdherence to themes\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0-8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0-8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cem\u003eQuality\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eTailoring\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0-12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0-12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eQuality in adherence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0-20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eAlliance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0-12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cem\u003eNA\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/br\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eParticipant characteristics and description of Fidelity, by D\u0026amp;I strategy\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003eAudit and feedback+\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\n \u003cp\u003eOngoing consultation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\n \u003cp\u003eActive dissemination\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;804\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;619\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;741\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;682\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;793\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;630\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;1423\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eBoy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e394 (49.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e310 (50.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e378 (51.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e326 (47.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e392 (49.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e312 (49.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e704 (49.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eGirl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e408 (50.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e307 (49.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e361 (48.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e354 (51.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e398 (50.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e317 (50.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e715 (50.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNeither\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e2 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e2 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e2 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e2 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e3 (0.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e1 (0.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e4 (0.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eHome language\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;801\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;605\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;740\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;666\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;782\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;624\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;1406\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eNorwegian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e667 (83.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e525 (86.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e600 (81.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e592 (88.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e647 (82.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e545 (87.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e1192 (84.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e134 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e80 (13.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e140 (18.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e74 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e135 (17.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e79 (12.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e214 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSelf-perceived family economy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;779\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;603\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;714\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;667\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;767\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;614\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;1381\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eWorse than others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e26 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e29 (4.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e22 (3.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e33 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e31 (4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e24 (3.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e55 (4.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAbout the same as others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e550 (70.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e416 (69.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e512 (71.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e454 (68.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e537 (70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e429 (69.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e966 (69.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eBetter than others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e202 (25.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e158 (26.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e180 (25.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e180 (27.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e199 (26.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e161 (26.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e360 (26.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eLiving situation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;801\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;605\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;740\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;666\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;782\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;624\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003en\u0026thinsp;=\u0026thinsp;1406\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eLive with both parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e559 (69.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e430 (71.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e512 (69.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e477 (71.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e537 (68.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e452 (72.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e989 (70.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOther living arrangement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e242 (30.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e175 (28.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e228 (30.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e189 (28.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e244 (31.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e172 (27.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e417 (29.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool nurse responses (range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;800\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;617\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;735\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;682\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;792\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;625\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;1417\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAdherence total (0\u0026ndash;11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e7.85 (2.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e9.30 (1.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e8.31 (1.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e8.67 (1.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e8.35 (1.84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e8.66 (1.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e8.48 (1.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAdherence, themes (0\u0026ndash;8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e5.73 (1.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e7.25 (0.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e6.23 (1.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e6.57 (1.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e6.28 (1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e6.52 (1.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e6.39 (1.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTailoring (0\u0026ndash;12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e8.26 (1.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e8.08 (1.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e8.14 (1.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e8.22 (1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e8.11 (1.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e8.28 (1.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e8.18 (1.59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eQuality in adherence (0\u0026ndash;20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e13.47 (2.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e13.33 (2.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e13.44 (2.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e13.37 (2.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e13.44 (2.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e13.36 (1.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e13.41 (2.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMean (SD) consultation duration (minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e31.24 (11.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e29.41 (12.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e29.60 (10.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e31.36 (13.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e30.45 (11.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e30.44 (13.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e30.44 (12.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudent responses (range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;797\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;603\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;731\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;669\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;773\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;627\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u0026thinsp;=\u0026thinsp;1400\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAdherence total (0\u0026ndash;10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e6.61 (1.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e7.79 (1.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e7.02 (2.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e7.23 (1.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e7.13 (1.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e7.10 (2.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e7.12 (1.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAdherence, themes (0\u0026ndash;8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e4.71 (1.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e5.85 (1.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e5.09 (1.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e5.32 (1.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e5.22 (1.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e5.18 (1.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e5.20 (1.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTailoring (0\u0026ndash;12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e7.83 (2.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e7.54 (2.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e7.74 (2.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e7.67 (2.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e7.87 (2.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e7.87 (2.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e7.71 (2.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eQuality in adherence (0\u0026ndash;20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e15.33 (2.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e14.99 (2.98)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e15.33 (2.99)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e15.13 (2.96)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e15.39 (3.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e14.93 (2.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e15.19 (2.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAlliance (0\u0026ndash;12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e10.35 (1.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e10.14 (1.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e10.32 (1.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e10.20 (1.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e10.34 (1.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e10.17 (1.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c8\"\u003e\n \u003cp\u003e10.26 (1.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cem\u003eEffect of the\u003c/em\u003e of the Dissemination \u0026amp; Implementation Strategies \u003cem\u003eon fidelity to the guideline, reported by\u003c/em\u003e School health nurses.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eEstimate\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e\n \u003cp\u003eEstimate\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c12\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\n \u003cp\u003eTotal adherence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"7\" nameend=\"c13\" namest=\"c7\"\u003e\n \u003cp\u003eAdherence to themes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"1\" nameend=\"c14\" namest=\"c14\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e-1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\n \u003cp\u003e-1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e-0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\n \u003cp\u003e-1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\n \u003cp\u003e-1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\n \u003cp\u003e-0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOngoing consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e-0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\n \u003cp\u003e-1.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.330\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\n \u003cp\u003e-0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\n \u003cp\u003e-1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e.275\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eActive dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\n \u003cp\u003e-0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.906\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\n \u003cp\u003e-0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e.792\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\n \u003cp\u003e-0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.593\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\n \u003cp\u003e-0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e.853\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Ongoing consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e-0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\n \u003cp\u003e-0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.600\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\n \u003cp\u003e-0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\n \u003cp\u003e-0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e.513\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOngoing consultation * Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\n \u003cp\u003e-0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.995\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\n \u003cp\u003e-0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\n \u003cp\u003e-0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e.656\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Ongoing consultation* Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e-0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\n \u003cp\u003e-1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.424\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\n \u003cp\u003e-0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\n \u003cp\u003e-0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e.393\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTailoring\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"8\" nameend=\"c14\" namest=\"c7\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality in adherence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.499\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\n \u003cp\u003e-0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e.968\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOngoing consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e-0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.702\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e-0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\n \u003cp\u003e-0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e.835\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eActive dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.910\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\n \u003cp\u003e-0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\n \u003cp\u003e1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e.717\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.307\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\n \u003cp\u003e-0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\n \u003cp\u003e1.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e.432\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Ongoing consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e-0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.731\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\n \u003cp\u003e-0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e.965\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOngoing consultation * Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e-0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.763\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\n \u003cp\u003e-0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e.912\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Ongoing consultation* Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e-0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.434\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\n \u003cp\u003e-0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\n \u003cp\u003e-1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e\n \u003cp\u003e.176\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\n \u003cp\u003e\u003cstrong\u003eConsultation Time (minutes)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c14\" namest=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-3.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e5.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e.685\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c14\" namest=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOngoing consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e-1.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-6.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e3.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cem\u003e.523\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c14\" namest=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eActive dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-4.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e5.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cem\u003e.755\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c14\" namest=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e1.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-3.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e6.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cem\u003e.656\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c14\" namest=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Ongoing consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-4.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e5.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cem\u003e.752\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c14\" namest=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOngoing consultation * Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e-3.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-7.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e1.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cem\u003e.228\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c14\" namest=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Ongoing consultation* Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\n \u003cp\u003e-3.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-8.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003e\u003cem\u003e.112\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c10\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c14\" namest=\"c14\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"14\"\u003eIntraclass Correlation Coefficients: Adherence total\u0026thinsp;=\u0026thinsp;0.649, Adherence to themes\u0026thinsp;=\u0026thinsp;0.599, Tailoring\u0026thinsp;=\u0026thinsp;0.556, Quality in Adherence\u0026thinsp;=\u0026thinsp;0.468, Consultation Time\u0026thinsp;=\u0026thinsp;0.480\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cem\u003eEffect\u003c/em\u003e of the Dissemination \u0026amp; Implementation Strategies \u003cem\u003eon fidelity to the guideline, reported by\u003c/em\u003e student.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eEstimate\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\" nameend=\"c8\" namest=\"c5\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\n \u003cp\u003eEstimate\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\" nameend=\"c14\" namest=\"c11\"\u003e\n \u003cp\u003eLower\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\" nameend=\"c17\" namest=\"c15\"\u003e\n \u003cp\u003eUpper\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\" nameend=\"c19\" namest=\"c18\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\n \u003cp\u003eTotal adherence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"12\" nameend=\"c19\" namest=\"c8\"\u003e\n \u003cp\u003eAdherence to themes\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e-1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-1.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e\n \u003cp\u003e-1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\n \u003cp\u003e-1.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e\n \u003cp\u003e-0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c19\" namest=\"c16\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOngoing consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e-0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003e.353\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e\n \u003cp\u003e-0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\n \u003cp\u003e-0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c19\" namest=\"c16\"\u003e\n \u003cp\u003e.308\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eActive dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003e.384\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\n \u003cp\u003e-0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c19\" namest=\"c16\"\u003e\n \u003cp\u003e.353\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003e.632\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\n \u003cp\u003e-0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c19\" namest=\"c16\"\u003e\n \u003cp\u003e.732\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Ongoing consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e-0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003e.204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e\n \u003cp\u003e-0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\n \u003cp\u003e-0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c19\" namest=\"c16\"\u003e\n \u003cp\u003e.254\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOngoing consultation * Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e-0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003e.207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e\n \u003cp\u003e-0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\n \u003cp\u003e-0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c19\" namest=\"c16\"\u003e\n \u003cp\u003e.123\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Ongoing consultation* Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003e.509\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e\n \u003cp\u003e-0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c15\" namest=\"c14\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c19\" namest=\"c16\"\u003e\n \u003cp\u003e.575\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTailoring\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"12\" nameend=\"c19\" namest=\"c8\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality in adherence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003e.337\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e\n \u003cp\u003e-0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c17\" namest=\"c15\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c19\" namest=\"c18\"\u003e\n \u003cp\u003e.376\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOngoing consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003e.873\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e\n \u003cp\u003e-0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c17\" namest=\"c15\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c19\" namest=\"c18\"\u003e\n \u003cp\u003e.662\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eActive dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003e.069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e\n \u003cp\u003e-0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c17\" namest=\"c15\"\u003e\n \u003cp\u003e1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c19\" namest=\"c18\"\u003e\n \u003cp\u003e.103\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003e.835\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e\n \u003cp\u003e-0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c17\" namest=\"c15\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c19\" namest=\"c18\"\u003e\n \u003cp\u003e.620\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Ongoing consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e-0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003e.622\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e\n \u003cp\u003e-0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e\n \u003cp\u003e-0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c17\" namest=\"c15\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c19\" namest=\"c18\"\u003e\n \u003cp\u003e.257\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eOngoing consultation * Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e-0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e-0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003e.041\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e\n \u003cp\u003e-0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e\n \u003cp\u003e-1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c17\" namest=\"c15\"\u003e\n \u003cp\u003e-0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c19\" namest=\"c18\"\u003e\n \u003cp\u003e.013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Ongoing consultation* Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e-0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\n \u003cp\u003e.963\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c14\" namest=\"c12\"\u003e\n \u003cp\u003e-0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c17\" namest=\"c15\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c19\" namest=\"c18\"\u003e\n \u003cp\u003e.957\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"12\" nameend=\"c19\" namest=\"c8\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlliance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\n \u003cp\u003e-0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c16\" namest=\"c13\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\n \u003cp\u003e.305\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c19\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\n \u003cp\u003eOngoing consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\n \u003cp\u003e-0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c16\" namest=\"c13\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\n \u003cp\u003e.419\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c19\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\n \u003cp\u003eActive dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\n \u003cp\u003e-0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c16\" namest=\"c13\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\n \u003cp\u003e.536\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c19\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\n \u003cp\u003e-0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\n \u003cp\u003e-0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c16\" namest=\"c13\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\n \u003cp\u003e.382\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c19\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Ongoing consultation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\n \u003cp\u003e-0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c16\" namest=\"c13\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\n \u003cp\u003e.748\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c19\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\n \u003cp\u003eOngoing consultation * Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\n \u003cp\u003e-0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\n \u003cp\u003e-0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c16\" namest=\"c13\"\u003e\n \u003cp\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\n \u003cp\u003e.042\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c19\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\n \u003cp\u003eAudit and feedback+* Ongoing consultation* Active dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\n \u003cp\u003e-0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e\n \u003cp\u003e-0.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\" nameend=\"c16\" namest=\"c13\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\" nameend=\"c18\" namest=\"c17\"\u003e\n \u003cp\u003e.387\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"1\" nameend=\"c19\" namest=\"c19\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"19\"\u003eIntraclass Correlation Coefficients: Adherence total: 0.266, Adherence to themes: 0.247, Tailoring: 0.075, Quality in adherence: 0.073, Alliance: 0.071\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Implementation strategies, Implementation mechanisms, Guideline, Fidelity, School health services, EPIS-framework, Multifactorial design, Hybrid type 2","lastPublishedDoi":"10.21203/rs.3.rs-9198555/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9198555/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003e Translating evidence-based guidelines into actionable improvements and sustained behavior change in practice remains a critical challenge across sectors. Evidence on strategies commonly used to disseminate and implement guidelines is scarce, and studies testing the effects and interactions of discrete and blended strategies are called for. This study disentangled a co-created blended implementation strategy into its discrete dissemination and implementation strategies: Audit and feedback+, Ongoing consultation, and Active dissemination. We examined the individual and interactional effects of these strategies on fidelity to a national guideline for health consultations with 8th -grade students in the Norwegian school health services.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eA hybrid type 2 cluster-randomized factorial trial was conducted in 25 municipalities and 49 schools. Three dissemination and implementation strategies constituted the experimental factors, yielding eight experimental conditions with different combinations of the strategies schools were randomized to. A total of 56 school nurses conducted consultations with 1400 students. Students and school nurses completed questionnaires at the beginning of the school year and after the 8th -grade consultation. Fidelity to the guideline for 8th -grade consultations was assessed by evaluating adherence to recommendations, the quality of adherence, and consultation duration. Linear mixed effects models were used to examine the effects.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003e School nurses and students reported moderate to high guideline fidelity across conditions, and few differential effects were found. Only the Audit and feedback+ strategy had a significant main effect on adherence, which was negative: nurses with Audit and feedback+ addressed fewer guideline-recommended themes during consultations.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003e No convincing differential or additive effects of the dissemination and implementation strategies on guideline fidelity were observed, which was generally high. Frequent fidelity measurement may itself have functioned as an implementation strategy, whereas Audit and feedback+ appeared to facilitate prioritization of consultation content without improving consultation quality. Overall, the study points to the importance of parsimony and mechanism-focused evaluation when designing and testing strategies for implementing evidence-based guidelines.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003eISRCTN reg.nr. 24173836\u003c/p\u003e","manuscriptTitle":"Disentangling the effects of strategies for guideline implementation in school health services: A hybrid type 2 cluster-randomized factorial trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-15 12:04:03","doi":"10.21203/rs.3.rs-9198555/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"260326865399766185802409523224588486689","date":"2026-05-04T23:26:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-08T05:15:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-07T09:32:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-24T06:10:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Implementation Science Communications","date":"2026-03-23T09:26:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9f165cf5-f8a5-4c88-81ce-ce46329ca177","owner":[],"postedDate":"April 15th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"260326865399766185802409523224588486689","date":"2026-05-04T23:26:04+00:00","index":18,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-15T12:04:04+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-15 12:04:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9198555","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9198555","identity":"rs-9198555","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}