The implementation of the Five Ways to Wellbeing innovation in 16 Norwegian schools: Lessons learned and future directions

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The Five Ways to Wellbeing framework has demonstrated effectiveness among adults but has not previously been implemented with children or adolescents. We adapted this framework into a school-based intervention called Five Ways to Wellbeing at School (5Ways@School) and implemented it in 16 schools with 3,324 students aged 10–16 years in Moss municipality, Norway. In this paper, we examine the implementation process and discuss how the intervention can be optimised for future use. Methods The 5Ways@School study employed a hybrid effectiveness-implementation design using a mixed methods approach. Data were collected through web-based questionnaires completed by students and teachers, supplemented by qualitative interviews with teachers, spanning November 2023 to December 2024. The study was longitudinal, two-armed, and non-randomised, with the intervention first administered to half of the students, while the remaining students served as a control group before receiving the intervention seven weeks later. This paper presents results based on questionnaires from 2,226 students and 113 teachers, analysed using descriptive statistics, analyses of variance (ANOVA), t-tests, and linear regression. Qualitative data from teachers’ free-text responses were analysed using thematic analysis (TA). Results User satisfaction with the intervention was moderate among students and teachers in Grades 5–7 but lower in Grades 8–10, particularly among teachers. Implementation fidelity was high across all grade levels. Teacher feedback indicated a need for greater flexibility to adapt the programme to classroom contexts, more age‑appropriate adjustments, and increased use of activity‑based learning. Conclusions The 5Ways@School programme is feasible but requires further refinement to enhance flexibility, support age‑appropriate adaptation, and incorporate more activity‑based content. Improving teacher engagement—especially in Grades 8–10—and more explicitly integrating the Five Ways into the broader school curriculum will be important for successful future implementation. Registry : ClinicalTrials.gov, TRN: NCT06144502, Registration date: 16 November 2023. Mental health promotion universal school prevention wellbeing Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Adolescents today face a growing number of stressors that challenge their mental health and wellbeing. Academic pressure, social media exposure, and uncertainty about the future, exacerbated by global issues such as climate change and political polarisation, contribute to increased levels of stress and mental health symptoms, which interfere with learning, relationships, and overall quality of life among youth (1-5). Schools offer an underutilised arena for promoting mental health and wellbeing. Since nearly all adolescents spend a significant portion of their lives in school, these settings provide unique opportunities to reach large populations with preventive and health-promoting interventions. School-based programmes teaching mental health literacy, emotional regulation, and coping strategies have demonstrated small to moderate individual effects, but their potential for population-level impact is substantial due to their universal reach and scalability (6-8). Investing in such programmes offer a practical and equitable way of equipping adolescents with tools to navigate the complexities of modern life. Teacher-delivered, curriculum-based such interventions may hold particular promise as they can be embedded sustainably within existing educational structures, yet remains surprisingly under-researched despite its potential (9). In Norway, the interdisciplinary topic “Health and Life Skills” was introduced in 2020 across all primary and secondary school levels. Its aim was to equip students with competencies that promote mental and physical health, support responsible life choices, and help them manage personal challenges and relationships (10). For this curricular change to positively influence students’ wellbeing, high-quality, research-based teaching materials are essential. To address this need, we developed Five Ways to Wellbeing at School (5Ways@School), a teaching programme for Grades 5 to 10 (ages 10–16), based on the Five Ways to Wellbeing framework (11, 12). Originating from the UK Government’s Foresight Programme on Mental Capital and Wellbeing, the framework identifies five empirically supported, activity-based strategies for enhancing wellbeing: Connect, Be Active, Take Notice, Keep Learning, and Give. Since its launch in 2008, the framework has been widely endorsed and implemented by public health authorities in the UK (13), and international studies have shown a positive dose-response relationship between engagement with its five activity-based components and increased wellbeing (14). A recent Norwegian RCT found that a web-based Five Ways intervention improved wellbeing and reduced illbeing among adults (12), likely via increased positive emotions (15) from engagement in the Five Ways activities (16). Given its universal design and simplicity, the Five Ways framework is well suited for adaptation to school settings. While several school programmes incorporate individual elements of the framework—such as the Kindness in the Classroom curriculum reflecting the “Give” component (13)—no studies have yet examined the full framework as a combined intervention in schools. Studying both the implementation and effectiveness of wellbeing-promoting school interventions is crucial. Real-world application often differs from controlled settings, and understanding how interventions are experienced by students and teachers is key to ensure their sustainability and impact (17). Implementation quality significantly influences outcomes (18), and hybrid effectiveness-implementation designs allow researchers to evaluate both whether the intervention works and how to best implement it (19). Bridging the gap between wellbeing research and real-life application is difficult and most research-informed interventions fail to implement in practice, often due to complex and unpredictable contexts, resource constraints, resistance to change, and lack of stakeholder involvement (20). Therefore, well-conducted effectiveness-implementation trials are needed to investigate the potential of wellbeing interventions in schools. In this paper, we investigate the implementation of the 5Ways@School intervention and explore directions for future improvement and scaling. To guide our exploration of implementation, we apply the Consolidated Framework for Implementation Research (CFIR), which includes five domains: the innovation itself, the individuals involved, the inner and outer settings, and the implementation process (21, 22). Methods Study design and data collection The 5Ways@School study is a hybrid effectiveness-implementation trial using mixed methods; web-based questionnaires completed by students and teachers, and qualitative interviews with teachers. It is a longitudinal, two-armed, non-randomised, controlled study, in which the intervention was first administered to half of the study population. The remaining half received it seven weeks later, hence serving as a control group for the first half during the initial period. We refer to our protocol paper for a more in-depth description of the study (23). We collected data from students at five time points, starting in November 2023, with follow-up collections in January, February, March, and November 2024. The time points were selected to align with the school’s annual schedule. Implementation measures were included in the questionnaire that students completed upon finishing the six-week intervention, in January (first group) and February (second group), respectively. Questionnaire-based implementation data were collected from the teachers after they had completed the teaching programme in their respective classes. Setting, participants, and recruitment The Norwegian compulsory education system is structured into two main levels: primary school, which includes grades 1-7 for children aged 6 to 12, and lower secondary school, which encompasses Grades 8-10 for students aged 13 to 16. Consultations with the municipality administration indicated a desire for health promoting teaching programme for students in Grades 5 through 10 (ages 10-16). The intervention and the student questionnaire were piloted in Råde, a neighbouring municipality (23). The full-scale trial was conducted at 16 out of 17 public schools in Moss municipality, excluding one school for 18 students with special needs. The teaching programme was delivered during regular teaching hours and was made compulsory for all students in 5 th to 10 th grade. Participation in data collection was voluntary, requiring consent from both students and their parents. All eligible students (N=3,324) were invited to participate via invitations sent to their parents through the schools' digital information channel. Students whose parents had consented were then invited to complete web-based questionnaires, administered in the classroom. Out of 3,324 eligible students, 2,226 (67%) participated in the collection of implementation data. The participation rate was lowest among 10 th grade students (53%) and highest among 6 th grade students (79%). Among the 156 teachers who delivered the intervention, 113 (72%) completed questionnaires; the participation rate ranging from 56% (7 th grade teachers) to 100% (10 th grade teachers). Figure 1 provides a flow chart of participating students, intervention periods and data collections, while Table 1 shows participation rates per school grade. Table 1. Participation rates per school grade Students Teachers Invited Participated Invited Participated 5th grade 531 377 71% 27 19 70% 6th grade 525 417 79% 26 17 65% 7th grade 562 407 72% 27 15 56% 8th grade 552 350 63% 25 23 92% 9th grade 561 363 65% 25 13 52% 10th grade 588 312 53% 26 26 100% Overall 3319 2226 67% 156 113 72% Note. Participation consent requests were sent from the school administration system to parents of all eligible students (n=3,324). Grade level information was missing for five students. Intervention The intervention was adapted from a Five Ways to Wellbeing course for adults (24, 25) and covered the five activity elements; Take Notice, Be Active, Keep Learning, Connect, and Give. It was provided by the class’s main teacher within a standard classroom setting. The teaching programme was spread out over six consecutive weeks, two 45-minute school lessons per week, culminating in a total of 12 school hours. Each instructional session consisted of short introductory texts, videos, and various forms of practical activities to be performed within the school setting. Each of the first five intervention weeks had one of the five activity domains in focus, while the last intervention week was spent on repetition of the prior weeks’ curriculum (i.e., all activity domains). The intervention was co-created with the publishing house, researchers (RBN and KGK), teachers, students, and personnel from the municipal school administration. Detailed information about the programme, including its components and delivery, is outlined in accordance with the Template for Intervention Description and Replication (TIDieR) checklist (see Additional file 2). To prepare the teachers for delivering the intervention, we (RBK and KGK) organised a full‑day seminar at a nearby hotel for all participating teachers, headmasters, school health nurses, and other school administrative staff (n = 600). Approximately half of the day was devoted to presenting the background, aims, and overall design of the research project. The remaining half day focused on introducing the teaching programme and providing teachers with practical training in its delivery. Measures Implementation outcomes were assessed through questionnaires completed by students and teachers, with the specific implementation measures detailed in Additional File 1. Responses were provided on four-point Likert scales ranging from ‘agree completely’ to ‘disagree completely,’ except for three teacher-specific questions about which of the five elements in 5Ways@School they found easiest and most challenging to teach, and which they considered most useful for students. In addition, teachers were asked to describe challenges they encountered when teaching 5Ways@School and to offer suggestions for improving the teaching materials. Answers to these questions were given in free-text format. Background variables were obtained from the students in the first data collection and included gender, school grade (Grades 5-10), whether both their parents were born in a country other than Norway, and whether they had one or two homes. Family socio-economic status was assessed with the Family Affluence Scale II (26, 27). Background variables were not collected from the teachers, except what school grade the teacher had taught the 5Ways@School. Data collection and storage We collected data by inviting students and teachers to complete web-based questionnaires at school, using “Nettskjema”, a digital survey solution developed and managed by the University of Oslo. Data storage and processing were performed on facilities owned by the University of Oslo, as described in the Additional file 1. Data analysis Quantitative data were analysed using R version 4.2.3 (28) and RStudio version 2023.03.1.446 (29). R packages used are listed in the Additional file 1 and our R code is available upon request. In survey-based research, some respondents may not devote sufficient attention or effort to answer all items, a behaviour referred to as careless or insufficient effort (C/IE) responding. Such responses can distort the data by either inflating or attenuating statistical associations, and may even generate spurious relationships among variables that are otherwise unrelated (30). To assess data quality, we examined the datasets for potential C/IE responders and identified 68 students (3.1%), while no C/IE responders were detected among the teachers. All student analyses were therefore conducted twice: once using the full dataset, and once with the 68 identified C/IE responders removed; the latter are presented in the current paper. Details of the C/IE detection procedures are provided in Additional file 1. Descriptive statistics were computed to characterise the participants and the implementation outcomes. Mean scores for user satisfaction were developed to further investigate how the implementation varied across different school grades. First, we reversed negatively worded items and assessed the internal consistency of the eleven student questionnaire items. An initial analysis revealed a Cronbach's alpha (95% Confidence Interval [CI]) of 0.80 (0.78-0.81) and an average inter-item correlation of 0.25. Three of the items had low corrected item-total correlations, indicating they did not correlate well with the overall scale. After their removal, reliability improved, with Cronbach’s alpha increasing to 0.88 (95% CI: 0.87–0.89) and the average inter-item correlation to 0.47, suggesting a more coherent measure. Mean score was defined as missing if a respondent had missing values on more than three of eight items. To assess associations between grade level and gender with student satisfaction, a linear regression was performed (see Additional file 1), with user satisfaction as the dependent variable and categorical indicators for school grade and gender as independent variables. For the teacher questionnaire, negatively worded items were reverse coded, and reliability assessed, resulting in an initial Cronbach's alpha (95% CI) of 0.82 (0.77-0.87) and an average inter-item correlation of 0.31. After removing two items which did not correlate well with the overall scale, Cronbach's alpha (95% CI) was estimated to 0.88 (0.85-0.91) and the average inter-item correlation to 0.52, suggesting a higher level of internal consistency. Based on the included items, a mean user satisfaction score was computed. Mean score was defined as missing if a respondent had missing values on more than three out of seven items. The three fidelity items showed low internal consistency (α = 0.32), reflecting that these items measured distinct aspects of fidelity. A mean fidelity score was computed and used as a formative measure (31), with both individual items and mean scores reported in the Results. Mean score was defined as missing if a respondent had missing values on more than one item. The associations between the teachers’ user satisfaction and fidelity were further investigated using linear regression. One-way analysis of variance (ANOVA) was used to examine differences in user satisfaction across grade levels for students and teachers, while multivariate analysis of variance (MANOVA) was used to test whether the early and late intervention groups differed in their responses. Independent samples t-tests compared user satisfaction between lower and upper grades students. Qualitative data from the teachers’ free-text questionnaire responses were analysed using elements from thematic analysis (TA) (32). TA is used in qualitative research to identify, analyse, and report patterns or themes within the data, and is a flexible and accessible approach that can be applied across a range of theoretical frameworks and research questions (32). In this paper, we applied “small-q” TA, i.e., analysis of qualitative data within a framework of (post)positivism (32). Our coding and theme development process is described in Additional file 1. Results Descriptive statistics for individual questionnaire items User satisfaction among students is presented in Fig. 2 . Younger students (5th to 7th grade) were generally more satisfied compared to the older students, for example measured by “I enjoyed learning about 5Ways@School” (60% vs. 51% agreed), “I learned something new, that I can make use of” (65% vs. 47%), “the teaching was boring” (66% vs. 76%), and “the teaching made me happy” (52% vs. 37%). Younger students were also more likely to report that other students should learn about the Five Ways. In contrast, younger and older students found the teaching programme equally easy to understand (77%) and that it had too few activities (69% vs. 71%). A minority of students reported that the teaching made them sad, afraid, or angry (11%). Aside from this, no harms or unintended effects were indicated. Additional user satisfaction analyses by gender and grade (see Supplementary File) revealed only minor differences. To investigate whether the user satisfaction among students differed between the early and late intervention groups, a one-way MANOVA was performed, including all the student user satisfaction items in the model. The multivariate test indicated no significant differences, Pillai’s trace = 0.0055, F (7, 1764) = 1.39, p = .21. User satisfaction among teachers is presented in Fig. 3 . The teachers in Grades 5–7 held different views compared to those in Grades 8–10 regarding several key aspects: Among the 5th to 7th grade teachers, 75% agreed that teaching life skills was a natural part of their job as compared to 41% of the 8th to 10th grade teachers. Furthermore, 86% of the 5th to 7th grade teachers felt motivated to teach the 5Ways@School and 65% enjoyed teaching it, while the comparable numbers for the 8th to 10th grade teachers were 53% and 34%, respectively. Likewise, 73% of the 5th to 7th grade teachers reported that their students learned something new and useful from the programme and 54% thought that the programme should be part of the regular curriculum in 5th to 7th grade, while only 28% of the 8th to 10th grade teachers thought that their students learned something new and useful and only 21% thought it should be part of the regular curriculum in 8th to 10th grade. Across school grades, a majority (57% vs. 60%) reported having received sufficient information and training before teaching the programme, and most teachers reported that the programme included too few activity options or exercises (71% vs. 85%). Fidelity among teachers is presented in Fig. 4 . The teachers in 5th to 7th grade were more likely to complete all six lessons in the programme, compared to the teachers in 8th to 10th grade (96% vs. 79%). There were only minor differences between the two groups of teachers in adherence to the manual (92% vs. 90%), and in the proportion who had abbreviated any of the lessons (56% vs. 53%). Analyses of mean scores and variances Mean score analyses of user satisfaction and fidelity are presented as box plots in Fig. 5 and as tables in the Supplementary File. The user satisfaction among students was slightly higher in Grades 5–7 (mean scores ranging from 2.47 to 2.77) as compared to Grades 8–10 (mean scores ranging from 2.35 to 2.40). A one-way ANOVA was conducted to examine differences in the students’ user satisfaction mean score across six grade levels. There was a statistically significant effect of school grade on mean scores, F (5, 2053) = 25.5, p < .001. Among the teachers, the difference in user satisfaction across school grade was even more pronounced, with the highest user satisfaction reported by the teachers in 6th grade (mean 2.91) and the lowest reported by the teachers in 9th grade (mean 1.77). Two one-way ANOVAs were conducted to examine differences across grade levels among teachers. User satisfaction scores differed significantly by grade, F (5, 107) = 7.41, p < .001, whereas fidelity scores did not, F (5, 104) = 1.13, p = 0.35. T-tests and regression analyses An independent samples Welch t-test was conducted to compare user satisfaction mean scores between 5th to 7th grade students and 8th to 10th grade students, showing a statistically significant difference, t (1955) = 9.00, p < .001, 95% CI [0.22, 0.34]. Homogeneity of variances was confirmed by Levene’s test ( p = .15), indicating that the assumption of equal variances was satisfied. The effect size, measured by Cohen’s d , was 0.41 (95% CI [0.32, 0.50]), indicating a small effect according to conventional benchmarks ( 33 ). We also investigated whether grade level and gender were associated with student satisfaction in a linear regression analysis (Supplementary File). The overall model was statistically significant, F (7, 2051) = 18.2, p < .001, indicating that grade and gender collectively explained about 6% of the variance in satisfaction scores (R² = 0.055). Students in 7th through 10th grades showed significantly lower satisfaction compared to 5th graders, with the strongest associations observed in 8th grade (β = -0.37, p < .001) and 9th grade (β = -0.37, p < .001). Gender was not associated with user satisfaction: students identifying as “Boy” (β ≈ 0.00, p = .96) or “Other/prefer not to answer” (β ≈ 0.02, p = .89) did not differ significantly from the reference group (“Girl”). An independent samples Welch t-test was conducted to compare teachers’ user satisfaction mean scores between two grade groups (Grades 5–7 vs. Grades 8–10). There was a statistically significant difference, t (105) = 6.00, p < .001, with a mean difference of 0.70 points (95% CI [0.46, 0.94]); teachers of Grades 5–7 (M = 2.9) reported higher satisfaction than those of Grades 8–10 (M = 2.2). Shapiro–Wilk tests did not indicate clear departures from normality (Grades 5–7: p = .20; Grades 8–10: p = .05). Levene’s test indicated unequal variances ( F ≈ 12.0, p < .001), so the Welch t-test, which does not assume equal variances, was used. The effect size was large, Cohen’s d = 1.00 (95% CI [0.65, 1.44]). A linear regression analysis confirmed that school grade was associated with teachers’ user satisfaction mean score (see Supplementary File). The model included categorical indicators for grades 6 through 10, with 5th grade serving as the reference category. Compared to teachers in lower grades, teachers in 8th − 10th grades reported significantly lower user satisfaction, with the lowest levels of satisfaction reported among 9th grade teachers (β = -1.09, p < .001). We used linear regression models to investigate whether the teachers’ user satisfaction was associated with their fidelity to the intervention (Supplementary File). Across all three models, user satisfaction was not significantly associated with fidelity, as measured by adherence to the teaching manual (Model 1), having completed all the six lessons (Model 2), or having abbreviated one or more lesson(s) (Model 3). Thematic analyses of teachers’ free text responses Thematic analyses of the challenges and advice from the teachers are reported in Tables 2 and 3 , respectively. The most reported challenges were that the programme was not engaging enough (41 mentions), there was too much text, reading, talking, and theory (23 mentions), too few activity options (21 mentions), and the programme was not sufficiently adapted to different age groups (18 mentions). Across the school grades, there were only minor differences between the challenges reported by the teachers, one being that only teachers in 8th to 10th grade felt that the programme took time away from other teaching obligations. The advice from the teachers was to reduce the amount of reading and talking, add more activity options and greater variety (40 mentions), and adapt and tailor the programme to different age groups (17 mentions). Several teachers also suggested to integrate the Five Ways into the school’s broader curriculum and annual plan over time (16 mentions). Again, there were minor differences across the school grades, with only teachers in 8th to 10th grade suggesting that the programme should be shortened (4 mentions) and/or not implemented in secondary schools (4 mentions). These qualitative findings align with the quantitative results, suggesting that lower satisfaction among students and teachers in grades 8 to 10 may reflect a lack of age-appropriate content, but also a lack of engagement among the teachers:, since 59% of the 8 to 10 grade teachers did not view teaching health and life skills through our intervention as part of their duty as teachers. Table 2 Thematic analysis of challenges reported by the teachers Theme Grade 5–7 Grade 8–10 The programme was not engaging enough 17 24 Too much text, reading, talking, and theory 10 13 Too few activities 6 14 The programme was not adapted to different age groups 7 11 Poor digital solution 3 7 The programme took time away from other teaching obligations 0 9 Did not fit into the annual plan/schedule 5 4 Unnecessary/useless programme 3 5 The information and training provided to the teachers was inadequate and came too late, and there was too little time for preparation 0 6 The programme was rigid and imposed on the teachers 2 4 Too little variety 1 4 The programme assumed homework, but we are a homework-free school 2 2 12 school hours is too little time for learning that leads to lasting change 2 1 Too much screen time 2 1 Repetitive and/or difficult surveys 3 0 Too little teaching material to fill the teaching hours 2 0 Table 3 Thematic analysis of advice from the teachers Theme Grade 5–7 Grade 8–10 Reduce reading and talking, add more activity (practical, concrete, physical, collaborative) and greater variety 11 29 Adapt the programme to different age groups 6 11 Work with the five habits over time, integrate them into the school’s broader curriculum and annual plan 3 13 Ask the teachers what they need; ensure better involvement and ownership among teachers 2 3 Improve the digital solution 1 3 Shorten the teaching programme 0 4 Do not implement the programme in secondary school 0 4 Add more engaging videos 3 0 Make the programme more flexible so teachers can tailor it to the needs of their class 1 2 Include an information page with contact details for support if students are struggling with mental health 0 1 Change the name of the programme to “5 Good Habits” 1 0 Involve parents in the teaching programme 1 0 Focus more on skills development 1 0 Introduce 30 minutes of physical activity each day during the programme period 1 0 Discussion In the present study, we investigate the implementation of the curriculum-based 5Ways@School intervention delivered by 156 teachers to 3,324 students in a naturalistic setting, exploring directions for future optimisation of the intervention and its implementation. To shed light on our findings, the following discussion is structured according to the different domains of the Consolidated Framework for Implementation Research (CFIR) ( 22 , 34 ). The Innovation Domain Most of the younger students enjoyed the innovation, found it easy to understand, and thought that other students should also receive the innovation. The older students were less satisfied with the innovation. This probably reflects that our innovation had a better fit for younger students, but could also reflect that older students are generally more negative to teaching materials they are presented with: Two surveys performed in Moss Municipality in Spring 2025 showed that 83% of the students in 8th to 10th grade found school generally boring, compared to 69% of the students in 5th to 7th grade ( 35 , 36 ). A small minority of the students reported that the teaching made them feel sad, afraid, or angry, a finding that needs to be explored in the future optimisation of the programme. However, the students gave one clear message: They wanted more activities. This finding is in line with the recommendations from OECD, that teachers should foster experiential learning, varied methods, rich interactions, and active practice of social-emotional skills ( 37 ). A majority of the 5th to 7th grade teachers enjoyed teaching the innovation and found it useful for their students, while most of the 8th to 10th grade teachers did not. Across the school grades, the teachers shared the students’ request for more activities. Students in active learning environments (e.g., problem-solving sessions) tend to learn more than those in traditional lectures, even if they feel they learn less ( 38 ). Some of the teachers commented on activities that had been successful and one 5th grade teacher wrote: “Really liked that [the students] were supposed to create weekly assignments for themselves and see how it went.” A 6th grade teacher commented: “[The intervention had] a lot of positive aspects. Perhaps even more student activity could be beneficial, such as the assignment where they were to take a photo of something new that they noticed in their local environment.” The teachers highlighted that our innovation was insufficiently adapted to different age groups. This was considered a substantial weakness, as children aged 10–12 are different from adolescents aged 13–16 in terms of cognitive development. Our finding that the teachers of the younger students were substantially more positive to the innovation points to the innovation being best suited for the younger students, but may also reflect that the majority of teachers of grades 8–10 did not view such innovations as part of their responsibilities and therefore did not bring as much enthusiasm and engagement into the teaching. However, some of the teachers reported that the innovation did not fit the youngest students: “My fifth graders are too young to really benefit from the [innovation]; much of it ‘goes over their heads’”, one 5th grade teacher commented. Several teachers mentioned that the digital infrastructure of the innovation would benefit from improvement: “The setup on the websites was very unintuitive. When 15 teachers are all spending a lot of time trying to figure out how the pages are structured, you feel like you’re wasting a lot of time,” one 9th grade teacher wrote. If the digital component of an innovation is ineffective, it can lead to teacher and student resistance, undermining the broader goals of the innovation ( 39 ). In our project, not only was the digital component itself criticized by the teachers, but also the amount of screen time. As one 5th grade teacher commented; “I found it contradictory that we encourage less screen time and more activity and awareness, while almost the entire programme takes place on a screen.” A 9th grade teacher wrote: “Students CANNOT sit with digital modules they can just click through and then expect to experience better mental health afterwards. You CANNOT learn about the importance of activities in everyday life by sitting still and working digitally.” The teachers also emphasized the innovation’s limited adaptability. However, it is difficult to determine whether this perceived lack of adaptability reflects an inherent characteristic of the innovation or whether it stemmed from the strict implementation requirements imposed by the research project. Because teachers were instructed not to modify or tailor the innovation, it was likely less well aligned with students’ needs than it might have been under typical conditions, thereby constraining teachers’ perceptions of its adaptability. As one 5th grade teacher explained: "When we were to implement [the innovation], we were strictly instructed to follow the programme slavishly. We could not adapt it to our group, or 'expand' the program as we usually would, to connect it with the rest of the school day." A 10th grade teacher commented: "I felt constrained by having to follow the programme exactly as required by the research project. I would have liked to go more in-depth and spend more time on each habit throughout the school year." A lack of adaptability has also been identified as a barrier in the implementation of other school‑based interventions, such as a teacher‑delivered mindfulness programme in the UK ( 40 ) and the SWIFT school wellness initiative in the USA ( 41 ). The purchase and operational costs associated with a given innovation could potentially represent a barrier to implementation. In this research project, these costs were minimal. Teachers prepared for implementation using their allocated planning time, their formal training consisted of a half-day introductory session and most teachers reported receiving sufficient information and training prior to delivering the innovation. The innovation itself was low-cost, consisting primarily of digital materials for classroom use, along with printable exercise sheets for student distribution. These low financial and logistical demands suggest that the innovation is well-suited for scale-up, potentially lowering the threshold for adoption in other schools. The Inner and Outer Settings Domains Our innovation was not administered in a vacuum; both the inner and outer settings impacted its implementation. The outer setting, being the context outside the individual schools where the innovation took place, were favourable for the innovation: The local politicians, the municipality administration and the local school authority all saw the need for promoting the students’ mental health and wellbeing, and they were highly supportive of the implementation of the innovation. The project was strengthened through partnerships and collaborations with external collaborators like the Norwegian Council for Mental Health, University of Oslo, the Norwegian Institute of Public Health, and the publisher. Its implementation was further facilitated by recent national policy changes, introducing the “health and life skills” training in schools. The inner setting, however, was not equally favourable for the implementation. Teachers noted that the innovation took valuable time from other teaching obligations and did not fit into the school’s annual plan, i.e. the innovation did not align with the school’s workflows, systems, and processes. As one 5th grade teacher wrote, “This programme completely clashes with other things that were scheduled for us at the start of the school year and has become a source of stress. But all in all, the topic is extremely important and relevant.” Hence, the timing of our intervention may have contributed to the teachers’ relatively low user satisfaction, underscoring the importance of engaging local stakeholders (the teachers) early and allowing for local adaptation of what period of the year to implement the innovation ( 42 ). In the full‑day preparation seminar, we may not have communicated clearly enough that the innovation supported students’ wellbeing and that its implementation was aligned with teachers’ responsibilities in “Health and Life Skills.”. This probably contributed to the relatively low motivation among the teachers in 8th to 10th grade, perhaps reflecting a stronger emphasis on academic instruction compared to teachers in 5th to 7th grade, who may be more accustomed to integrating social and emotional learning into their teaching practices. Although fidelity in this study was high, teachers who do not perceive the programme as part of their professional responsibilities may experience lower satisfaction and motivation – even when an innovation is well-designed. Perceiving it as a burden or as “extra work” can reduce teacher’s enthusiasm and engagement. Our findings align well with McLoughlin et al., that poor communication and competing priorities (such as academic attainment) were major barriers to implementation of the SWIFT school wellness intervention ( 41 ). The Implementation Process Domain Central to a well-planned implementation process is gathering information about the priorities, preferences, and needs of both innovation deliverers (here: the teachers) and innovation recipients (the students); as well as assessing the context for barriers and facilitators to implementation and delivery of the innovation. In our study, the teachers emphasized the importance of practitioner input: “You need to listen to actual educators when it comes to how this programme can be implemented”, a 9th grade teacher wrote, while a 10th grade teacher commented: “There was an underlying assumption that all teachers would feel strong motivation for the [innovation] despite not having any sense of ownership. For teachers, it was perceived as if these topics are not usually addressed in school.” Inadequate information gathering from teachers and insufficient adaptation to their needs were also identified as barriers to motivation and ownership of the aforementioned SWIFT intervention ( 41 ). In developing of our innovation, we involved both students and teachers, and we piloted the innovation in seven school classes in Råde municipality, however, the extent of user involvement and information collected was likely insufficient. Successful implementation depends on motivating both innovation deliverers to implement the programme and recipients to actively participate. Feedback from the teachers revealed that some of them felt compelled, rather than encouraged, to deliver the innovation. As one 5th grade teacher commented: “It is completely wrong to impose on us when we should do things, with deadlines and so on.” Similarly, lack of engagement and motivation among staff was identified as a barrier to the implementation of a whole school mindfulness programme in UK ( 40 ). Given that only 41% of teachers in grades 8 to 10 viewed teaching life skills as a natural part of their role, and that 47% did not feel motivated to teach the intervention, our intervention struggled to foster meaningful engagement. One challenge lies in shifting teachers’ perceptions, especially when they do not see this as an inherent part of their professional responsibilities. As one 9th grade teacher remarked: “It feels like a complete override and an assumption that teachers did not previously focus on this or work with students’ life skills in the past.” The fact that teachers in Grades 8 to 10 reported less motivation and enjoyment when teaching the programme, may have negatively influenced the students’ experience of the programme. This may partly explain lower user satisfaction among students in Grades 8–10 relative to those in Grades 5–7. Although teachers reported a need for greater involvement in both the development and implementation of the intervention, overall implementation fidelity was high across grade levels, with the highest fidelity observed in Grades 5–7 compared to Grades 8–10. More teachers in 5th to 7th grade completed all six lessons, as compared to the teachers in 8th to 10th grade. This difference could reflect higher work pressure and more constraints on the teachers in the higher grades, but also their attitude towards teaching the 5Ways@School as beyond their professional responsibility. One implication is that more students in Grades 8–10 received a lower dose of intervention, compared to students in Grades 5–7. However, more teachers in Grades 5–7 had to abbreviate lesson(s) as compared to teachers in Grades 8–10, but this difference was not substantial. Five ways to improved intervention Taken together, the feedback from students and teachers indicated that the 5Ways@School was a feasible and quite well-received innovation, but also that it requires further refinement to function optimally across grade levels and contexts. A distillation of this feedback revealed five ways to optimize the innovation and its implementation: Adjust the content of the innovation: Reduce reading, talking, and screen time; add more activities, skills training, and variety so that the programme becomes more engaging for the students. Adapt the innovation to different age groups and make it flexible so that the teachers can tailor it to their classes’ specific needs. Integrate the innovation with the broader school curriculum and the school’s annual plan, so that its use will not interfere with other teaching obligations or exams. Work with the five components of the innovation over a longer period and involve the parents in the process. Deep learning and change in behaviour take time; and 12 school hours is insufficient. Co-develop version 2.0 of the innovation with teachers and students. The innovation should be informed by the teachers’ experience and expertise, and the teachers’ motivation for teaching the programme must be addressed and encouraged, if the programme is to be successfully and sustainably implemented. Strengths and limitations A key strength of our study is its real-world context: we examined the implementation of a teaching programme across nearly all public schools in a Norwegian municipality. This large-scale approach enabled us to recruit a substantial number of students and teachers, generating a rich dataset on the implementation process. Studies of this size are uncommon, and our findings may inform the design of future implementation research and guide health-promoting school interventions. Another strength is the relatively high participation rates among both students (67%) and teachers (72%), supporting the robustness of our findings. Because the teaching programme was integrated into the regular curriculum and mandatory for all students and teachers, bias related to intervention participation was minimized. However, selection bias remains a concern. Students whose parents declined or failed to provide consent may differ systematically from those who participated, introducing uncertainty about representativeness. Attrition also limits our ability to capture the perspectives of all intended participants, which affects the completeness of our evaluation of 5Ways@School. Students and teachers who did not participate could potentially differ in systematic ways from those who did participate, leading us to under- or overestimate user satisfaction and fidelity. Possible reasons for lower student participation include insufficient information provided to students and parents/guardians. Additionally, the requirement for active parental consent—mandated by the Regional Ethics Committee—likely contributed to non-response. This is supported by comparison with Ungdata surveys in the same municipality, which used passive consent and achieved higher participation rates (88% in Grades 5–7 and 82% in Grades 8–10) ( 35 , 36 ). Another limitation is the absence of standardized implementation assessment instruments. While our user satisfaction measures demonstrated strong internal consistency and face validity, reliance on a non-standardized tool limits comparability with existing literature and may reduce generalizability. Nevertheless, several of our items closely align with validated measures. For example, our statements “I enjoyed learning about 5Ways@School” and “I enjoyed teaching the 5Ways@School” resemble items such as “I like [INTERVENTION]” in the Acceptability of Intervention Measure (AIM) ( 43 ). Finally, our qualitative data collection was restricted to teachers. Resource constraints led us to collect only quantitative data from students, but qualitative insights from students could have provided valuable perspectives on programme implementation. Conclusions Our findings show that the 5Ways@School had acceptable user satisfaction among students and teachers in Grades 5–7, and that the implementation fidelity among teachers was high in all grades studied. However, this high fidelity likely came at a cost: teachers noted that the guidelines provided by researchers constrained their ability to adapt the program to their students’ needs, and they expressed concern about this lack of flexibility. While the programme appears feasible, it requires further development and optimisation based on feedback from students and teachers before broader implementation. Further investigation is also needed to understand why a minority of students reported negative emotional responses to the lessons, as these insights will be important for refining the programme. Future improvements to the Ways@School intervention should prioritise co‑creation of content with students and teachers, increased use of activity‑based learning, and greater flexibility to support age‑appropriate adaptation. Because user satisfaction is a key determinant of successful implementation, future work should also examine how teacher engagement can be improved, particularly among teachers in Grades 8–10. Presenting teachers with research demonstrating that increased student wellbeing can support academic performance may be one strategy for strengthening engagement ( 44 ). In addition, future implementation may benefit from embedding the intervention more explicitly within the broader school curriculum, integrating the Five Ways into regular school routines over a longer period of time. Overall, 5Ways@School shows promise as a teacher‑delivered, curriculum‑based intervention that can be integrated into existing educational structures to support adolescent wellbeing. Abbreviations 5Ways@School The Five Ways to Wellbeing at School Intervention ANOVA analysis of variance CI Confidence Interval MANOVA multivariate analysis of variance NOK Norwegian kroner (currency) TA thematic analysis TIDieR Checklist Template for Intervention Description and Replication Checklist Declarations Ethics approval and consent to participate Ethics approval was obtained from the Regional Committee for Medical and Health Research Ethics in South East Norway (reference no. 491440). Informed consent was sought from parents before students were invited to complete questionnaires. Consent for a student's participation was required from at least one parent; however, if either parent expressed dissent, the student was not eligible to participate in the study. The students themselves were also required to provide informed consent and could withdraw at any time, with their data deleted unless already used in statistical analyses. All teachers who had taught the 5Ways@School were invited to complete a questionnaire and participate in qualitative interviews, with participation being voluntary and based on informed consent. Due to a low response rate initially, teachers were offered a chance to win one of ten NOK 1000 (≈90€) gift vouchers. Teachers could withdraw consent at any time, with their data deleted unless already used in analyses. Consent for publication Not applicable. Availability of data and materials The datasets generated and analysed during the current study are not publicly available due to restrictions in the ethics approval obtained for this project. Competing interests KGK is employed as Chief Medical Officer at Moss Municipality, where the study was carried out. The authors declare no competing interests. Funding This project was funded by Moss Municipality, Norwegian Institute of Public Health, PROMENTA research centre, University of Oslo, the County Governor of Oslo and Viken, and the Norwegian Research Council (project no. 345560 and 288083). The study was designed and developed in dialogue with Moss Municipality. The County Governor and the Research Council had no role in the research process. Authors' contributions KGK designed the study, conducted the analyses and wrote the paper; EB, NOL, RRC, and RBN designed the study and revised the paper. Acknowledgements The authors wish to thank all participating students, teachers, and school leaders in Moss and Råde municipalities. We also want to thank the Norwegian Council for Mental Health and Skolerom Publishing House for collaborating with us on this project, and Professor Åshild Lappegard Hauge for invaluable advice on qualitative methods. References Sacco R, Camilleri N, Eberhardt J, Umla-Runge K, Newbury-Birch D. A systematic review and meta-analysis on the prevalence of mental disorders among children and adolescents in Europe. Eur Child Adolesc Psychiatry. 2024;33(9):2877–94. Marquez J, Taylor L, Boyle L, Zhou W, De Neve J-E. Child and Adolescent Well-Being: Global Trends, Challenges and Opportunities. In: Helliwell JF, Layard R, Sachs JD, De Neve J-E, Aknin LB, Wang S, editors. World Happiness Report 2024. Oxford: University of Oxford: Wellbeing Research Centre; 2024. pp. 61–102. Potrebny T, Nilsen SA, Bakken A, von Soest T, Kvaløy K, Samdal O, et al. Secular trends in mental health problems among young people in Norway: a review and meta-analysis. European Child & Adolescent Psychiatry; 2024. Baird S, Choonara S, Azzopardi PS, Banati P, Bessant J, Biermann O, et al. A call to action: the second Lancet Commission on adolescent health and wellbeing. Lancet. 2025;405(10493):1945–2022. Mohan A, Kostelecky SM, Sivakumar A, Khalil M, Clark H. Improving adolescent wellbeing is an urgent global priority. BMJ. 2022;379:o2551. World Health Organization. Division of Mental Health. Life skills education for children and adolescents in schools. Pt. 1, Introduction to life skills for psychosocial competence. Pt. 2, Guidelines to facilitate the development and implementation of life skills programmes. Geneva; 1994 1994. Report No.: WHO/MNH/PSF/93.7A.Rev.2 Contract No.: WHO/MNH/PSF/93.7A.Rev.2. Cohen KA, Ito S, Ahuvia IL, Yang Y, Zhang Y, Renshaw TL et al. Brief School-Based Interventions Targeting Student Mental Health or Well-Being: A Systematic Review and Meta-Analysis. Clinical Child and Family Psychology Review. 2024. Martinsen KD, Rasmussen LMP, Wentzel-Larsen T, Holen S, Sund AM, Løvaas MES, et al. Prevention of anxiety and depression in school children: Effectiveness of the transdiagnostic EMOTION program. J Consult Clin Psychol. 2019;87(2):212–9. Lawson GM, Orapallo A, Ginsburg GS, Brewton A, Baker CN, Azad G. 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Mackay L, Egli V, Booker LJ, Prendergast K. New Zealand's engagement with the Five Ways to Wellbeing: evidence from a large cross-sectional survey. Kotuitui. 2019;14(2):230–44. Prydz MB, Bjørndal LD, Czajkowski NO, Røysamb E, Nes RB. Direct and indirect effects of a digital Five Ways to Wellbeing intervention: A network intervention analysis. Behav Res Ther. 2025;191:104781. Prydz MB, Czajkowski NO, Røysamb E, Rodríguez-Cano R, Nes RB. Exploring Mechanisms in a Digital Five Ways to Wellbeing Intervention: A Multilevel Mediation Analysis. SSRN Preprint [Internet]. 2025 2025-08-05. Available from: https://ssrn.com/abstract=5357441 Schultes M-T. An introduction to implementation evaluation of school-based interventions. Eur J Dev Psychol. 2023;20(1):189–201. Durlak JA, DuPre EP. Implementation Matters: A Review of Research on the Influence of Implementation on Program Outcomes and the Factors Affecting Implementation. Am J Community Psychol. 2008;41(3):327–50. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50(3):217–26. Alley ZM, Chapman JE, Schaper H, Saldana L. The relative value of Pre-Implementation stages for successful implementation of evidence-informed programs. Implement Sci. 2023;18(1):30. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10(1):53. Reardon CM, Damschroder LJ, Ashcraft LE, Kerins C, Bachrach RL, Nevedal AL, et al. The Consolidated Framework for Implementation Research (CFIR) User Guide: a five-step guide for conducting implementation research using the framework. Implement Sci. 2025;20(1):39. Krogshus KG, Bjertness E, Czajkowski NO, Rodriguez-Cano R, Nes RB. Study protocol for 5Ways@School – An implementation and effectiveness trial of a school-based wellbeing intervention in 16 schools in Norway. Scand J Public Health.0(0):14034948251370109. Eilertsen MN. Ragnhild Bang. Improving Wellbeing, Health and Work Adherence Effects of the 5 Ways to Wellbeing Course ClinicalTrials.gov: U.S. National Library of Medicine; 2020 [Available from: https://clinicaltrials.gov/ct2/show/NCT04668560 Prydz MB, Czajkowski NO, Eilertsen M, Røysamb E, Nes RB. A Web-Based Intervention Using Five Ways to Wellbeing to Promote Well-Being and Mental Health: Randomized Controlled Trial. JMIR Ment Health. 2024;11:e49050. Currie CE, Elton RA, Todd J, Platt S. Indicators of socioeconomic status for adolescents: the WHO Health Behaviour in School-aged Children Survey. Health Educ Res. 1997;12(3):385–97. Currie C, Molcho M, Boyce W, Holstein B, Torsheim T, Richter M. Researching health inequalities in adolescents: the development of the Health Behaviour in School-Aged Children (HBSC) family affluence scale. Soc Sci Med. 2008;66(6):1429–36. R Core Team. R: A Language and Environment for Statistical Computing. 4.2.3 ed. Vienna, Austria: R Foundation for Statistical Computing; 2023. Posit team. RStudio: Integrated Development Environment for R. 2023.03.1.446 ed. Boston, MA: Posit Software, PBC; 2023. Curran PG. Methods for the detection of carelessly invalid responses in survey data. J Exp Soc Psychol. 2016;66:4–19. Coltman T, Devinney TM, Midgley DF, Venaik S. Formative versus reflective measurement models: Two applications of formative measurement. J Bus Res. 2008;61(12):1250–62. Braun V, Clarke V. Thematic analysis: a practical guide. Los Angeles, California: SAGE; 2022. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, N. J: Laurence Erlbaum; 1988. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50. Ungdatasenteret U. 2025: Moss kommune - Hovedrapport for ungdomstrinnet. Oslo: Velferdsforskningsinstituttet NOVA; 2025. Ungdatasenteret. Ungdata junior 2025: Moss kommune - Hovedrapport for mellomtrinnet 5. – 7. klasse. Oslo: Velferdsforskningsinstituttet NOVA; 2025. OECD. Unlocking High-Quality Teaching. Paris; 2025. Deslauriers L, McCarty LS, Miller K, Callaghan K, Kestin G. Measuring actual learning versus feeling of learning in response to being actively engaged in the classroom. Proceedings of the National Academy of Sciences. 2019;116(39):19251–7. Bećirović S. Challenges and Barriers for Effective Integration of Technologies into Teaching and Learning. SpringerBriefs in Education. Singapore: Singapore: Springer; 2023. pp. 123–33. Hudson KG, Lawton R, Hugh-Jones S. Factors affecting the implementation of a whole school mindfulness program: a qualitative study using the consolidated framework for implementation research. BMC Health Serv Res. 2020;20(1):133. McLoughlin GM, Sweeney R, Liechty L, Lee JA, Rosenkranz RR, Welk GJ. Evaluation of a Large-Scale School Wellness Intervention Through the Consolidated Framework for Implementation Research (CFIR): Implications for Dissemination and Sustainability. Front Health Serv. 2022;Volume 2–2022. OECD. An implementation framework for effective change in schools. Paris; 2020. Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):108. Kaya M, Erdem C. Students’ Well-Being and Academic Achievement: A Meta-Analysis Study. Child Indic Res. 2021;14(5):1743–67. Additional Declarations Competing interest reported. KGK is employed as Chief Medical Officer at Moss Municipality, where the study was carried out. The authors declare no competing interests. Supplementary Files additionalfile1.pdf Additional file 1 (additional_file_1.pdf): Supplementary Methods and Results additionalfile2.pdf Additional file 2 (additional_file_2.pdf): Completed TIDieR checklist additionalfile3.pdf Additional file 3 (additional_file_3.pdf): Students’ questionnaire (Norwegian) additionalfile4.pdf Additional file 4 (additional_file_4.pdf): Teachers’ questionnaire (Norwegian) Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-8926279","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":596000070,"identity":"a25af3dc-7b36-401d-9ed0-c54d60edfd3b","order_by":0,"name":"Kristian Green Krogshus","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAr0lEQVRIiWNgGAWjYBACCQbGBhAtx8BMkpYDDAzGpGgBAqCWxAaiHSY5+3Dz5w+/7qVvOM58gLmggggt0nyJbRIH+4pzNxxmS2CecYYILXI8jG0MB3sSgFp4DJh524jT0vwBqCXdgGgt0jyMDRIHfiQkEK9FsoexTeJsQ4LhTKBfDvMQ4xeJM+yPP1T8SZDnO3/44GMeYkIMDBih7jlArAYg+EOC2lEwCkbBKBh5AABPTjSaimfJPAAAAABJRU5ErkJggg==","orcid":"","institution":"University of Oslo","correspondingAuthor":true,"prefix":"","firstName":"Kristian","middleName":"Green","lastName":"Krogshus","suffix":""},{"id":596000071,"identity":"1cbf0ddf-5012-457a-a024-b4f4e6fde009","order_by":1,"name":"Espen Bjertness","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Espen","middleName":"","lastName":"Bjertness","suffix":""},{"id":596000072,"identity":"1dc4fb6f-a764-4ef4-b1fc-40f717c96261","order_by":2,"name":"Nikolai Olavi Czajkowski","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Nikolai","middleName":"Olavi","lastName":"Czajkowski","suffix":""},{"id":596000073,"identity":"06ac365d-0ebd-435d-a87b-e613d0c13e86","order_by":3,"name":"Rubén Rodríguez-Cano","email":"","orcid":"","institution":"European Union Drugs Agency (EUDA)","correspondingAuthor":false,"prefix":"","firstName":"Rubén","middleName":"","lastName":"Rodríguez-Cano","suffix":""},{"id":596000074,"identity":"0bfaec73-eaf4-41ce-8069-9c2fe20f0620","order_by":4,"name":"Ragnhild Bang Nes","email":"","orcid":"","institution":"University of Oslo","correspondingAuthor":false,"prefix":"","firstName":"Ragnhild","middleName":"Bang","lastName":"Nes","suffix":""}],"badges":[],"createdAt":"2026-02-20 13:10:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8926279/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8926279/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103601906,"identity":"5d1fc2f1-974c-4d88-ad71-bdf912ac6cd7","added_by":"auto","created_at":"2026-02-27 14:11:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":262329,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of participating students, intervention periods, and data collections. Types of variables collected are indicated in parentheses: B=Background, I=Implementation, W=Wellbeing. 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KGK is employed as Chief Medical Officer at Moss Municipality, where the study was carried out. The authors declare no competing interests.","formattedTitle":"The implementation of the Five Ways to Wellbeing innovation in 16 Norwegian schools: Lessons learned and future directions","fulltext":[{"header":"Background","content":"\u003cp\u003eAdolescents today face a growing number of stressors that challenge their mental health and wellbeing. Academic pressure, social media exposure, and uncertainty about the future, exacerbated by global issues such as climate change and political polarisation, contribute to increased levels of stress and mental health symptoms, which\u0026nbsp;interfere with learning, relationships, and overall quality of life\u0026nbsp;among youth\u0026nbsp;(1-5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSchools offer an underutilised arena for promoting mental health and wellbeing. Since nearly all adolescents spend a significant portion of their lives in school, these settings provide unique opportunities to reach large populations with preventive and health-promoting interventions. School-based programmes teaching mental health literacy, emotional regulation, and coping strategies have demonstrated small to moderate individual effects, but their potential for population-level impact is substantial due to their universal reach and scalability (6-8). Investing in such programmes offer a practical and equitable way of equipping adolescents with tools to navigate the complexities of modern life. Teacher-delivered, curriculum-based such interventions may hold particular promise as they can be embedded sustainably within existing educational structures, yet remains surprisingly under-researched despite its potential (9).\u003c/p\u003e\n\u003cp\u003eIn Norway, the interdisciplinary topic \u0026ldquo;Health and Life Skills\u0026rdquo; was introduced in 2020 across all primary and secondary school levels. Its aim was to equip students with competencies that promote mental and physical health, support responsible life choices, and help them manage personal challenges and relationships (10). For this curricular change to positively influence students\u0026rsquo; wellbeing, high-quality, research-based teaching materials are essential. To address this need, we developed Five Ways to Wellbeing at School (5Ways@School), a teaching programme for Grades 5 to 10 (ages 10\u0026ndash;16), based on the Five Ways to Wellbeing framework (11, 12). Originating from the UK Government\u0026rsquo;s Foresight Programme on Mental Capital and Wellbeing, the framework identifies five empirically supported, activity-based strategies for enhancing wellbeing: Connect, Be Active, Take Notice, Keep Learning, and Give. Since its launch in 2008, the framework has been widely endorsed and implemented by public health authorities in the UK (13), and international studies have shown a positive dose-response relationship between engagement with its five activity-based components and increased wellbeing (14). A recent Norwegian RCT found that a web-based Five Ways intervention improved wellbeing and reduced illbeing among adults (12), likely via\u0026nbsp;increased\u0026nbsp;positive emotions\u0026nbsp;(15)\u0026nbsp;from engagement in the Five Ways activities\u0026nbsp;(16).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven its universal design and simplicity, the Five Ways framework is well suited for adaptation to school settings. While several school programmes incorporate individual elements of the framework\u0026mdash;such as the Kindness in the Classroom curriculum reflecting the \u0026ldquo;Give\u0026rdquo; component (13)\u0026mdash;no studies have yet examined the full framework as a combined intervention in schools.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStudying both the implementation and effectiveness of wellbeing-promoting school interventions is crucial. Real-world application often differs from controlled settings, and understanding how interventions are experienced by students and teachers is key to ensure their sustainability and impact (17).\u0026nbsp;Implementation quality significantly influences outcomes\u0026nbsp;(18),\u0026nbsp;and hybrid effectiveness-implementation designs allow researchers to evaluate both whether the intervention works and how to best implement it\u0026nbsp;(19). Bridging the gap between wellbeing research and real-life application is difficult and most research-informed interventions fail to implement in practice, often due to complex and unpredictable contexts, resource constraints, resistance to change, and lack of stakeholder involvement\u0026nbsp;(20). Therefore, well-conducted effectiveness-implementation trials are needed to investigate the potential of wellbeing interventions in schools.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this paper, we investigate the implementation of the 5Ways@School intervention and explore directions for future improvement and scaling. To guide our exploration of implementation, we apply the Consolidated Framework for Implementation Research (CFIR), which includes five domains: the innovation itself, the individuals involved, the inner and outer settings, and the implementation process (21, 22).\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eStudy design and data collection\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe 5Ways@School study is a hybrid effectiveness-implementation trial using mixed methods; web-based questionnaires completed by students and teachers, and qualitative interviews with teachers. It is a longitudinal, two-armed, non-randomised, controlled study, in which the intervention was first administered to half of the study population. The remaining half received it seven weeks later, hence serving as a control group for the first half during the initial period. We refer to our protocol paper for a more in-depth description of the study (23).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe collected data from students at five time points, starting in November 2023, with follow-up collections in January, February, March, and November 2024. The time points were selected to align with the school\u0026rsquo;s annual schedule. Implementation measures were included in the questionnaire that students completed upon finishing the six-week intervention, in January (first group) and February (second group), respectively. Questionnaire-based implementation data were collected from the teachers after they had completed the teaching programme in their respective classes.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eSetting, participants, and recruitment\u003c/h2\u003e\n\u003cp\u003eThe Norwegian compulsory education system is structured into two main levels: primary school, which includes grades 1-7 for children aged 6 to 12, and lower secondary school, which encompasses Grades 8-10 for students aged 13 to 16. Consultations with the municipality administration indicated a desire for health promoting teaching programme for students in Grades 5 through 10 (ages 10-16). The intervention and the student questionnaire were piloted in R\u0026aring;de, a neighbouring municipality (23).\u0026nbsp;The full-scale trial was conducted at 16 out of 17 public schools in Moss municipality, excluding one school for 18 students with special needs. The teaching programme was delivered during regular teaching hours and was made compulsory for all students in 5\u003csup\u003eth\u003c/sup\u003e to 10\u003csup\u003eth\u003c/sup\u003e grade. Participation in data collection was voluntary, requiring consent from both students and their parents. All eligible students (N=3,324) were invited to participate via invitations sent to their parents through the schools\u0026apos; digital information channel. Students whose parents had consented were then invited to complete web-based questionnaires, administered in the classroom. Out of 3,324 eligible students, 2,226 (67%) participated in the collection of implementation data. The participation rate was lowest among 10\u003csup\u003eth\u003c/sup\u003e grade students (53%) and highest among 6\u003csup\u003eth\u003c/sup\u003e grade students (79%). Among the 156 teachers who delivered the intervention, 113 (72%) completed questionnaires; the participation rate ranging from 56% (7\u003csup\u003eth\u003c/sup\u003e grade teachers) to 100% (10\u003csup\u003eth\u003c/sup\u003e grade teachers). Figure 1 provides a flow chart of participating students, intervention periods and data collections, while Table 1 shows participation rates per school grade.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"481\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eParticipation rates per school grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 182px;\"\u003e\n \u003cp\u003eStudents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 160px;\"\u003e\n \u003cp\u003eTeachers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003eInvited\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 117px;\"\u003e\n \u003cp\u003eParticipated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003eInvited\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 100px;\"\u003e\n \u003cp\u003eParticipated\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e5th grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e531\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e377\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e70%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e6th grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e525\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e417\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e65%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e7th grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e562\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e407\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e72%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e56%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e8th grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e552\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e350\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e63%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e92%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e9th grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e561\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e363\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e65%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e52%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e10th grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e588\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e53%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3319\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2226\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e67%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e156\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e113\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e72%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e Participation consent requests were sent from the school administration system to parents of all eligible students (n=3,324). Grade level information was missing for five students.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eIntervention\u003c/h2\u003e\n\u003cp\u003eThe intervention was adapted from a Five Ways to Wellbeing course for adults (24, 25) and covered the five activity elements; Take Notice, Be Active, Keep Learning, Connect, and Give. It was provided by the class\u0026rsquo;s main teacher within a standard classroom setting. The teaching programme was spread out over six consecutive weeks, two 45-minute school lessons per week, culminating in a total of 12 school hours. Each instructional session consisted of short introductory texts, videos, and various forms of practical activities to be performed within the school setting. Each of the first five intervention weeks had one of the five activity domains in focus, while the last intervention week was spent on repetition of the prior weeks\u0026rsquo; curriculum (i.e., all activity domains). The intervention was co-created with the publishing house, researchers (RBN and KGK), teachers, students, and personnel from the municipal school administration. Detailed information about the programme, including its components and delivery, is outlined in accordance with the Template for Intervention Description and Replication (TIDieR) checklist (see\u0026nbsp;Additional file 2).\u003c/p\u003e\n\u003cp\u003eTo prepare the teachers for delivering the intervention, we (RBK and KGK) organised a full‑day seminar at a nearby hotel for all participating teachers, headmasters, school health nurses, and other school administrative staff (n = 600). Approximately half of the day was devoted to presenting the background, aims, and overall design of the research project. The remaining half day focused on introducing the teaching programme and providing teachers with practical training in its delivery.\u003c/p\u003e\n\u003ch2\u003eMeasures\u003c/h2\u003e\n\u003cp\u003eImplementation outcomes were assessed through questionnaires completed by students and teachers, with the specific implementation measures detailed in Additional File 1. Responses were provided on four-point Likert scales ranging from \u0026lsquo;agree completely\u0026rsquo; to \u0026lsquo;disagree completely,\u0026rsquo; except for three teacher-specific questions about which of the five elements in 5Ways@School they found easiest and most challenging to teach, and which they considered most useful for students. In addition, teachers were asked to describe challenges they encountered when teaching 5Ways@School and to offer suggestions for improving the teaching materials. Answers to these questions were given in free-text format.\u003c/p\u003e\n\u003cp\u003eBackground variables were obtained from the students in the first data collection and included gender, school grade (Grades 5-10), whether both their parents were born in a country other than Norway, and whether they had one or two homes. Family socio-economic status was assessed with the Family Affluence Scale II (26, 27). Background variables were not collected from the teachers, except what school grade the teacher had taught the 5Ways@School.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData collection and storage\u003c/h2\u003e\n\u003cp\u003eWe collected data by inviting students and teachers to complete web-based questionnaires at school, using \u0026ldquo;Nettskjema\u0026rdquo;, a digital survey solution developed and managed by the University of Oslo. Data storage and processing were performed on facilities owned by the University of Oslo, as described in the\u0026nbsp;Additional file 1.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eQuantitative data were analysed using R version 4.2.3 (28) and RStudio version 2023.03.1.446 (29). R packages used are listed in the Additional file 1 and our R code is available upon request.\u003c/p\u003e\n\u003cp\u003eIn survey-based research, some respondents may not devote sufficient attention or effort to answer all items, a behaviour referred to as careless or insufficient effort (C/IE) responding. Such responses can distort the data by either inflating or attenuating statistical associations, and may even generate spurious relationships among variables that are otherwise unrelated (30). To assess data quality, we examined the datasets for potential C/IE responders and identified 68 students (3.1%), while no C/IE responders were detected among the teachers. All student analyses were therefore conducted twice: once using the full dataset, and once with the 68 identified C/IE responders removed; the latter are presented in the current paper. Details of the C/IE detection procedures are provided in Additional file 1.\u003c/p\u003e\n\u003cp\u003eDescriptive statistics were computed to characterise the participants and the implementation outcomes.\u0026nbsp;Mean scores for user satisfaction were developed to further investigate how the implementation varied across different school grades. First, we reversed negatively worded items and assessed the internal consistency of the eleven student questionnaire items. An initial analysis revealed a Cronbach\u0026apos;s alpha (95% Confidence Interval [CI]) of 0.80 (0.78-0.81) and an average inter-item correlation of 0.25. Three of the items had low corrected item-total correlations, indicating they did not correlate well with the overall scale. After their removal, reliability improved, with Cronbach\u0026rsquo;s alpha increasing to 0.88 (95% CI: 0.87\u0026ndash;0.89) and the average inter-item correlation to 0.47, suggesting a more coherent measure.\u0026nbsp;Mean score was defined as missing if a respondent had missing values on more than three of eight items. To assess associations between grade level and gender with student satisfaction, a linear regression was performed (see\u0026nbsp;Additional file 1), with user satisfaction as the dependent variable and categorical indicators for school grade and gender as independent variables.\u003c/p\u003e\n\u003cp\u003eFor the teacher questionnaire, negatively worded items were reverse coded, and reliability assessed, resulting in an initial Cronbach\u0026apos;s alpha (95% CI) of 0.82 (0.77-0.87) and an average inter-item correlation of 0.31. After removing two items which did not correlate well with the overall scale, Cronbach\u0026apos;s alpha (95% CI) was estimated to 0.88 (0.85-0.91) and the average inter-item correlation to 0.52, suggesting a higher level of internal consistency. Based on the included items, a mean user satisfaction score was computed. Mean score was defined as missing if a respondent had missing values on more than three out of seven items.\u003c/p\u003e\n\u003cp\u003eThe three fidelity items showed low internal consistency (\u0026alpha; = 0.32), reflecting that these items measured distinct aspects of fidelity. A mean fidelity score was computed and used as a formative measure (31), with both individual items and mean scores reported in the Results. Mean score was defined as missing if a respondent had missing values on more than one item. The\u0026nbsp;associations between the teachers\u0026rsquo; user satisfaction and fidelity were further investigated using linear regression.\u003c/p\u003e\n\u003cp\u003eOne-way analysis of variance (ANOVA) was used to examine differences in user satisfaction across grade levels for students and teachers, while multivariate analysis of variance (MANOVA) was used to test whether the early and late intervention groups differed in their responses. Independent samples t-tests compared user satisfaction between lower and upper grades students.\u0026nbsp;\u003cbr\u003e\u0026nbsp;Qualitative data from the teachers\u0026rsquo; free-text questionnaire responses were analysed using elements from thematic analysis (TA) (32). TA is used in qualitative research to identify, analyse, and report patterns or themes within the data, and is a flexible and accessible approach that can be applied across a range of theoretical frameworks and research questions (32). In this paper, we applied \u0026ldquo;small-q\u0026rdquo; TA, \u0026nbsp;i.e., analysis of qualitative data within a framework of (post)positivism (32). Our coding and theme development process is described in Additional file 1.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDescriptive statistics for individual questionnaire items\u003c/p\u003e \u003cp\u003eUser satisfaction among students is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Younger students (5th to 7th grade) were generally more satisfied compared to the older students, for example measured by \u0026ldquo;I enjoyed learning about 5Ways@School\u0026rdquo; (60% vs. 51% agreed), \u0026ldquo;I learned something new, that I can make use of\u0026rdquo; (65% vs. 47%), \u0026ldquo;the teaching was boring\u0026rdquo; (66% vs. 76%), and \u0026ldquo;the teaching made me happy\u0026rdquo; (52% vs. 37%). Younger students were also more likely to report that other students should learn about the Five Ways. In contrast, younger and older students found the teaching programme equally easy to understand (77%) and that it had too few activities (69% vs. 71%). A minority of students reported that the teaching made them sad, afraid, or angry (11%). Aside from this, no harms or unintended effects were indicated.\u003c/p\u003e \u003cp\u003eAdditional user satisfaction analyses by gender and grade (see Supplementary File) revealed only minor differences. To investigate whether the user satisfaction among students differed between the early and late intervention groups, a one-way MANOVA was performed, including all the student user satisfaction items in the model. The multivariate test indicated no significant differences, Pillai\u0026rsquo;s trace\u0026thinsp;=\u0026thinsp;0.0055, \u003cem\u003eF\u003c/em\u003e(7, 1764)\u0026thinsp;=\u0026thinsp;1.39, \u003cem\u003ep\u003c/em\u003e = .21.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eUser satisfaction among teachers is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The teachers in Grades 5\u0026ndash;7 held different views compared to those in Grades 8\u0026ndash;10 regarding several key aspects: Among the 5th to 7th grade teachers, 75% agreed that teaching life skills was a natural part of their job as compared to 41% of the 8th to 10th grade teachers. Furthermore, 86% of the 5th to 7th grade teachers felt motivated to teach the 5Ways@School and 65% enjoyed teaching it, while the comparable numbers for the 8th to 10th grade teachers were 53% and 34%, respectively. Likewise, 73% of the 5th to 7th grade teachers reported that their students learned something new and useful from the programme and 54% thought that the programme should be part of the regular curriculum in 5th to 7th grade, while only 28% of the 8th to 10th grade teachers thought that their students learned something new and useful and only 21% thought it should be part of the regular curriculum in 8th to 10th grade. Across school grades, a majority (57% vs. 60%) reported having received sufficient information and training before teaching the programme, and most teachers reported that the programme included too few activity options or exercises (71% vs. 85%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eFidelity among teachers\u003c/b\u003e is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The teachers in 5th to 7th grade were more likely to complete all six lessons in the programme, compared to the teachers in 8th to 10th grade (96% vs. 79%). There were only minor differences between the two groups of teachers in adherence to the manual (92% vs. 90%), and in the proportion who had abbreviated any of the lessons (56% vs. 53%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAnalyses of mean scores and variances\u003c/p\u003e \u003cp\u003e \u003cb\u003eMean score analyses of user satisfaction and fidelity\u003c/b\u003e are presented as box plots in Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and as tables in the Supplementary File. The user satisfaction among students was slightly higher in Grades 5\u0026ndash;7 (mean scores ranging from 2.47 to 2.77) as compared to Grades 8\u0026ndash;10 (mean scores ranging from 2.35 to 2.40). A one-way ANOVA was conducted to examine differences in the students\u0026rsquo; user satisfaction mean score across six grade levels. There was a statistically significant effect of school grade on mean scores, \u003cem\u003eF\u003c/em\u003e(5, 2053)\u0026thinsp;=\u0026thinsp;25.5, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001.\u003c/p\u003e \u003cp\u003eAmong the teachers, the difference in user satisfaction across school grade was even more pronounced, with the highest user satisfaction reported by the teachers in 6th grade (mean 2.91) and the lowest reported by the teachers in 9th grade (mean 1.77). Two one-way ANOVAs were conducted to examine differences across grade levels among teachers. User satisfaction scores differed significantly by grade, \u003cem\u003eF\u003c/em\u003e(5, 107)\u0026thinsp;=\u0026thinsp;7.41, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, whereas fidelity scores did not, \u003cem\u003eF\u003c/em\u003e(5, 104)\u0026thinsp;=\u0026thinsp;1.13, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.35.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eT-tests and regression analyses\u003c/p\u003e \u003cp\u003eAn independent samples Welch t-test was conducted to compare user satisfaction mean scores between 5th to 7th grade students and 8th to 10th grade students, showing a statistically significant difference, \u003cem\u003et\u003c/em\u003e(1955)\u0026thinsp;=\u0026thinsp;9.00, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, 95% CI [0.22, 0.34]. Homogeneity of variances was confirmed by Levene\u0026rsquo;s test (\u003cem\u003ep\u003c/em\u003e = .15), indicating that the assumption of equal variances was satisfied. The effect size, measured by Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e, was 0.41 (95% CI [0.32, 0.50]), indicating a small effect according to conventional benchmarks (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe also investigated whether grade level and gender were associated with student satisfaction in a linear regression analysis (Supplementary File). The overall model was statistically significant, \u003cem\u003eF\u003c/em\u003e(7, 2051)\u0026thinsp;=\u0026thinsp;18.2, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, indicating that grade and gender collectively explained about 6% of the variance in satisfaction scores (R\u0026sup2; = 0.055). Students in 7th through 10th grades showed significantly lower satisfaction compared to 5th graders, with the strongest associations observed in 8th grade (β = -0.37, p \u0026lt; .001) and 9th grade (β = -0.37, p \u0026lt; .001). Gender was not associated with user satisfaction: students identifying as \u0026ldquo;Boy\u0026rdquo; (β\u0026thinsp;\u0026asymp;\u0026thinsp;0.00, p = .96) or \u0026ldquo;Other/prefer not to answer\u0026rdquo; (β\u0026thinsp;\u0026asymp;\u0026thinsp;0.02, p = .89) did not differ significantly from the reference group (\u0026ldquo;Girl\u0026rdquo;).\u003c/p\u003e \u003cp\u003eAn independent samples Welch t-test was conducted to compare teachers\u0026rsquo; user satisfaction mean scores between two grade groups (Grades 5\u0026ndash;7 vs. Grades 8\u0026ndash;10). There was a statistically significant difference, \u003cem\u003et\u003c/em\u003e(105)\u0026thinsp;=\u0026thinsp;6.00, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001, with a mean difference of 0.70 points (95% CI [0.46, 0.94]); teachers of Grades 5\u0026ndash;7 (M\u0026thinsp;=\u0026thinsp;2.9) reported higher satisfaction than those of Grades 8\u0026ndash;10 (M\u0026thinsp;=\u0026thinsp;2.2). Shapiro\u0026ndash;Wilk tests did not indicate clear departures from normality (Grades 5\u0026ndash;7: p = .20; Grades 8\u0026ndash;10: \u003cem\u003ep\u003c/em\u003e = .05). Levene\u0026rsquo;s test indicated unequal variances (\u003cem\u003eF\u003c/em\u003e\u0026thinsp;\u0026asymp;\u0026thinsp;12.0, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001), so the Welch t-test, which does not assume equal variances, was used. The effect size was large, Cohen\u0026rsquo;s \u003cem\u003ed\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.00 (95% CI [0.65, 1.44]). A linear regression analysis confirmed that school grade was associated with teachers\u0026rsquo; user satisfaction mean score (see Supplementary File). The model included categorical indicators for grades 6 through 10, with 5th grade serving as the reference category. Compared to teachers in lower grades, teachers in 8th \u0026minus;\u0026thinsp;10th grades reported significantly lower user satisfaction, with the lowest levels of satisfaction reported among 9th grade teachers (β = -1.09, p \u0026lt; .001).\u003c/p\u003e \u003cp\u003eWe used linear regression models to investigate whether the teachers\u0026rsquo; user satisfaction was associated with their fidelity to the intervention (Supplementary File). Across all three models, user satisfaction was not significantly associated with fidelity, as measured by adherence to the teaching manual (Model 1), having completed all the six lessons (Model 2), or having abbreviated one or more lesson(s) (Model 3).\u003c/p\u003e \u003cp\u003eThematic analyses of teachers\u0026rsquo; free text responses\u003c/p\u003e \u003cp\u003eThematic analyses of the challenges and advice from the teachers are reported in Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e, respectively. The most reported challenges were that the programme was not engaging enough (41 mentions), there was too much text, reading, talking, and theory (23 mentions), too few activity options (21 mentions), and the programme was not sufficiently adapted to different age groups (18 mentions). Across the school grades, there were only minor differences between the challenges reported by the teachers, one being that only teachers in 8th to 10th grade felt that the programme took time away from other teaching obligations.\u003c/p\u003e \u003cp\u003eThe advice from the teachers was to reduce the amount of reading and talking, add more activity options and greater variety (40 mentions), and adapt and tailor the programme to different age groups (17 mentions). Several teachers also suggested to integrate the Five Ways into the school\u0026rsquo;s broader curriculum and annual plan over time (16 mentions). Again, there were minor differences across the school grades, with only teachers in 8th to 10th grade suggesting that the programme should be shortened (4 mentions) and/or not implemented in secondary schools (4 mentions).\u003c/p\u003e \u003cp\u003eThese qualitative findings align with the quantitative results, suggesting that lower satisfaction among students and teachers in grades 8 to 10 may reflect a lack of age-appropriate content, but also a lack of engagement among the teachers:, since 59% of the 8 to 10 grade teachers did not view teaching health and life skills through our intervention as part of their duty as teachers.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThematic analysis of challenges reported by the teachers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade 5\u0026ndash;7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGrade 8\u0026ndash;10\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe programme was not engaging enough\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo much text, reading, talking, and theory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo few activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe programme was not adapted to different age groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoor digital solution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe programme took time away from other teaching obligations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDid not fit into the annual plan/schedule\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnnecessary/useless programme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe information and training provided to the teachers was inadequate and came too late, and there was too little time for preparation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe programme was rigid and imposed on the teachers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo little variety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe programme assumed homework, but we are a homework-free school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12 school hours is too little time for learning that leads to lasting change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo much screen time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRepetitive and/or difficult surveys\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToo little teaching material to fill the teaching hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThematic analysis of advice from the teachers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGrade 5\u0026ndash;7\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGrade 8\u0026ndash;10\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReduce reading and talking, add more activity (practical, concrete, physical, collaborative) and greater variety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdapt the programme to different age groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork with the five habits over time, integrate them into the school\u0026rsquo;s broader curriculum and annual plan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsk the teachers what they need; ensure better involvement and ownership among teachers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImprove the digital solution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShorten the teaching programme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDo not implement the programme in secondary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdd more engaging videos\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMake the programme more flexible so teachers can tailor it to the needs of their class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInclude an information page with contact details for support if students are struggling with mental health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange the name of the programme to \u0026ldquo;5 Good Habits\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvolve parents in the teaching programme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFocus more on skills development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntroduce 30 minutes of physical activity each day during the programme period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, we investigate the implementation of the curriculum-based 5Ways@School intervention delivered by 156 teachers to 3,324 students in a naturalistic setting, exploring directions for future optimisation of the intervention and its implementation. To shed light on our findings, the following discussion is structured according to the different domains of the Consolidated Framework for Implementation Research (CFIR) (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Innovation Domain\u003c/p\u003e \u003cp\u003eMost of the younger students enjoyed the innovation, found it easy to understand, and thought that other students should also receive the innovation. The older students were less satisfied with the innovation. This probably reflects that our innovation had a better fit for younger students, but could also reflect that older students are generally more negative to teaching materials they are presented with: Two surveys performed in Moss Municipality in Spring 2025 showed that 83% of the students in 8th to 10th grade found school generally boring, compared to 69% of the students in 5th to 7th grade (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). A small minority of the students reported that the teaching made them feel sad, afraid, or angry, a finding that needs to be explored in the future optimisation of the programme. However, the students gave one clear message: They wanted more activities. This finding is in line with the recommendations from OECD, that teachers should foster experiential learning, varied methods, rich interactions, and active practice of social-emotional skills (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA majority of the 5th to 7th grade teachers enjoyed teaching the innovation and found it useful for their students, while most of the 8th to 10th grade teachers did not. Across the school grades, the teachers shared the students\u0026rsquo; request for more activities. Students in active learning environments (e.g., problem-solving sessions) tend to learn more than those in traditional lectures, even if they feel they learn less (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Some of the teachers commented on activities that had been successful and one 5th grade teacher wrote: \u0026ldquo;Really liked that [the students] were supposed to create weekly assignments for themselves and see how it went.\u0026rdquo; A 6th grade teacher commented: \u0026ldquo;[The intervention had] a lot of positive aspects. Perhaps even more student activity could be beneficial, such as the assignment where they were to take a photo of something new that they noticed in their local environment.\u0026rdquo;\u003c/p\u003e \u003cp\u003eThe teachers highlighted that our innovation was insufficiently adapted to different age groups. This was considered a substantial weakness, as children aged 10\u0026ndash;12 are different from adolescents aged 13\u0026ndash;16 in terms of cognitive development. Our finding that the teachers of the younger students were substantially more positive to the innovation points to the innovation being best suited for the younger students, but may also reflect that the majority of teachers of grades 8\u0026ndash;10 did not view such innovations as part of their responsibilities and therefore did not bring as much enthusiasm and engagement into the teaching. However, some of the teachers reported that the innovation did not fit the youngest students: \u0026ldquo;My fifth graders are too young to really benefit from the [innovation]; much of it \u0026lsquo;goes over their heads\u0026rsquo;\u0026rdquo;, one 5th grade teacher commented.\u003c/p\u003e \u003cp\u003eSeveral teachers mentioned that the digital infrastructure of the innovation would benefit from improvement: \u0026ldquo;The setup on the websites was very unintuitive. When 15 teachers are all spending a lot of time trying to figure out how the pages are structured, you feel like you\u0026rsquo;re wasting a lot of time,\u0026rdquo; one 9th grade teacher wrote. If the digital component of an innovation is ineffective, it can lead to teacher and student resistance, undermining the broader goals of the innovation (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). In our project, not only was the digital component itself criticized by the teachers, but also the amount of screen time. As one 5th grade teacher commented; \u0026ldquo;I found it contradictory that we encourage less screen time and more activity and awareness, while almost the entire programme takes place on a screen.\u0026rdquo; A 9th grade teacher wrote: \u0026ldquo;Students CANNOT sit with digital modules they can just click through and then expect to experience better mental health afterwards. You CANNOT learn about the importance of activities in everyday life by sitting still and working digitally.\u0026rdquo;\u003c/p\u003e \u003cp\u003eThe teachers also emphasized the innovation\u0026rsquo;s limited adaptability. However, it is difficult to determine whether this perceived lack of adaptability reflects an inherent characteristic of the innovation or whether it stemmed from the strict implementation requirements imposed by the research project. Because teachers were instructed not to modify or tailor the innovation, it was likely less well aligned with students\u0026rsquo; needs than it might have been under typical conditions, thereby constraining teachers\u0026rsquo; perceptions of its adaptability. As one 5th grade teacher explained: \"When we were to implement [the innovation], we were strictly instructed to follow the programme slavishly. We could not adapt it to our group, or 'expand' the program as we usually would, to connect it with the rest of the school day.\" A 10th grade teacher commented: \"I felt constrained by having to follow the programme exactly as required by the research project. I would have liked to go more in-depth and spend more time on each habit throughout the school year.\" A lack of adaptability has also been identified as a barrier in the implementation of other school‑based interventions, such as a teacher‑delivered mindfulness programme in the UK (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) and the SWIFT school wellness initiative in the USA (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe purchase and operational costs associated with a given innovation could potentially represent a barrier to implementation. In this research project, these costs were minimal. Teachers prepared for implementation using their allocated planning time, their formal training consisted of a half-day introductory session and most teachers reported receiving sufficient information and training prior to delivering the innovation. The innovation itself was low-cost, consisting primarily of digital materials for classroom use, along with printable exercise sheets for student distribution. These low financial and logistical demands suggest that the innovation is well-suited for scale-up, potentially lowering the threshold for adoption in other schools.\u003c/p\u003e \u003cp\u003eThe Inner and Outer Settings Domains\u003c/p\u003e \u003cp\u003eOur innovation was not administered in a vacuum; both the inner and outer settings impacted its implementation. The outer setting, being the context outside the individual schools where the innovation took place, were favourable for the innovation: The local politicians, the municipality administration and the local school authority all saw the need for promoting the students\u0026rsquo; mental health and wellbeing, and they were highly supportive of the implementation of the innovation. The project was strengthened through partnerships and collaborations with external collaborators like the Norwegian Council for Mental Health, University of Oslo, the Norwegian Institute of Public Health, and the publisher. Its implementation was further facilitated by recent national policy changes, introducing the \u0026ldquo;health and life skills\u0026rdquo; training in schools.\u003c/p\u003e \u003cp\u003eThe inner setting, however, was not equally favourable for the implementation. Teachers noted that the innovation took valuable time from other teaching obligations and did not fit into the school\u0026rsquo;s annual plan, i.e. the innovation did not align with the school\u0026rsquo;s workflows, systems, and processes. As one 5th grade teacher wrote, \u0026ldquo;This programme completely clashes with other things that were scheduled for us at the start of the school year and has become a source of stress. But all in all, the topic is extremely important and relevant.\u0026rdquo; Hence, the timing of our intervention may have contributed to the teachers\u0026rsquo; relatively low user satisfaction, underscoring the importance of engaging local stakeholders (the teachers) early and allowing for local adaptation of what period of the year to implement the innovation (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). In the full‑day preparation seminar, we may not have communicated clearly enough that the innovation supported students\u0026rsquo; wellbeing and that its implementation was aligned with teachers\u0026rsquo; responsibilities in \u0026ldquo;Health and Life Skills.\u0026rdquo;. This probably contributed to the relatively low motivation among the teachers in 8th to 10th grade, perhaps reflecting a stronger emphasis on academic instruction compared to teachers in 5th to 7th grade, who may be more accustomed to integrating social and emotional learning into their teaching practices. Although fidelity in this study was high, teachers who do not perceive the programme as part of their professional responsibilities may experience lower satisfaction and motivation \u0026ndash; even when an innovation is well-designed. Perceiving it as a burden or as \u0026ldquo;extra work\u0026rdquo; can reduce teacher\u0026rsquo;s enthusiasm and engagement. Our findings align well with McLoughlin et al., that poor communication and competing priorities (such as academic attainment) were major barriers to implementation of the SWIFT school wellness intervention (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Implementation Process Domain\u003c/p\u003e \u003cp\u003eCentral to a well-planned implementation process is gathering information about the priorities, preferences, and needs of both innovation deliverers (here: the teachers) and innovation recipients (the students); as well as assessing the context for barriers and facilitators to implementation and delivery of the innovation. In our study, the teachers emphasized the importance of practitioner input: \u0026ldquo;You need to listen to actual educators when it comes to how this programme can be implemented\u0026rdquo;, a 9th grade teacher wrote, while a 10th grade teacher commented: \u0026ldquo;There was an underlying assumption that all teachers would feel strong motivation for the [innovation] despite not having any sense of ownership. For teachers, it was perceived as if these topics are not usually addressed in school.\u0026rdquo; Inadequate information gathering from teachers and insufficient adaptation to their needs were also identified as barriers to motivation and ownership of the aforementioned SWIFT intervention (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). In developing of our innovation, we involved both students and teachers, and we piloted the innovation in seven school classes in R\u0026aring;de municipality, however, the extent of user involvement and information collected was likely insufficient.\u003c/p\u003e \u003cp\u003eSuccessful implementation depends on motivating both innovation deliverers to implement the programme and recipients to actively participate. Feedback from the teachers revealed that some of them felt compelled, rather than encouraged, to deliver the innovation. As one 5th grade teacher commented: \u0026ldquo;It is completely wrong to impose on us when we should do things, with deadlines and so on.\u0026rdquo; Similarly, lack of engagement and motivation among staff was identified as a barrier to the implementation of a whole school mindfulness programme in UK (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Given that only 41% of teachers in grades 8 to 10 viewed teaching life skills as a natural part of their role, and that 47% did not feel motivated to teach the intervention, our intervention struggled to foster meaningful engagement. One challenge lies in shifting teachers\u0026rsquo; perceptions, especially when they do not see this as an inherent part of their professional responsibilities. As one 9th grade teacher remarked: \u0026ldquo;It feels like a complete override and an assumption that teachers did not previously focus on this or work with students\u0026rsquo; life skills in the past.\u0026rdquo; The fact that teachers in Grades 8 to 10 reported less motivation and enjoyment when teaching the programme, may have negatively influenced the students\u0026rsquo; experience of the programme. This may partly explain lower user satisfaction among students in Grades 8\u0026ndash;10 relative to those in Grades 5\u0026ndash;7.\u003c/p\u003e \u003cp\u003eAlthough teachers reported a need for greater involvement in both the development and implementation of the intervention, overall implementation fidelity was high across grade levels, with the highest fidelity observed in Grades 5\u0026ndash;7 compared to Grades 8\u0026ndash;10. More teachers in 5th to 7th grade completed all six lessons, as compared to the teachers in 8th to 10th grade. This difference could reflect higher work pressure and more constraints on the teachers in the higher grades, but also their attitude towards teaching the 5Ways@School as beyond their professional responsibility. One implication is that more students in Grades 8\u0026ndash;10 received a lower dose of intervention, compared to students in Grades 5\u0026ndash;7. However, more teachers in Grades 5\u0026ndash;7 had to abbreviate lesson(s) as compared to teachers in Grades 8\u0026ndash;10, but this difference was not substantial.\u003c/p\u003e \u003cp\u003eFive ways to improved intervention\u003c/p\u003e \u003cp\u003eTaken together, the feedback from students and teachers indicated that the 5Ways@School was a feasible and quite well-received innovation, but also that it requires further refinement to function optimally across grade levels and contexts. A distillation of this feedback revealed five ways to optimize the innovation and its implementation:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAdjust the content of the innovation: Reduce reading, talking, and screen time; add more activities, skills training, and variety so that the programme becomes more engaging for the students.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAdapt the innovation to different age groups and make it flexible so that the teachers can tailor it to their classes\u0026rsquo; specific needs.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIntegrate the innovation with the broader school curriculum and the school\u0026rsquo;s annual plan, so that its use will not interfere with other teaching obligations or exams.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWork with the five components of the innovation over a longer period and involve the parents in the process. Deep learning and change in behaviour take time; and 12 school hours is insufficient.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCo-develop version 2.0 of the innovation with teachers and students. The innovation should be informed by the teachers\u0026rsquo; experience and expertise, and the teachers\u0026rsquo; motivation for teaching the programme must be addressed and encouraged, if the programme is to be successfully and sustainably implemented.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eStrengths and limitations\u003c/p\u003e \u003cp\u003eA key strength of our study is its real-world context: we examined the implementation of a teaching programme across nearly all public schools in a Norwegian municipality. This large-scale approach enabled us to recruit a substantial number of students and teachers, generating a rich dataset on the implementation process. Studies of this size are uncommon, and our findings may inform the design of future implementation research and guide health-promoting school interventions.\u003c/p\u003e \u003cp\u003eAnother strength is the relatively high participation rates among both students (67%) and teachers (72%), supporting the robustness of our findings. Because the teaching programme was integrated into the regular curriculum and mandatory for all students and teachers, bias related to intervention participation was minimized. However, selection bias remains a concern. Students whose parents declined or failed to provide consent may differ systematically from those who participated, introducing uncertainty about representativeness. Attrition also limits our ability to capture the perspectives of all intended participants, which affects the completeness of our evaluation of 5Ways@School. Students and teachers who did not participate could potentially differ in systematic ways from those who did participate, leading us to under- or overestimate user satisfaction and fidelity. Possible reasons for lower student participation include insufficient information provided to students and parents/guardians. Additionally, the requirement for active parental consent\u0026mdash;mandated by the Regional Ethics Committee\u0026mdash;likely contributed to non-response. This is supported by comparison with Ungdata surveys in the same municipality, which used passive consent and achieved higher participation rates (88% in Grades 5\u0026ndash;7 and 82% in Grades 8\u0026ndash;10) (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother limitation is the absence of standardized implementation assessment instruments. While our user satisfaction measures demonstrated strong internal consistency and face validity, reliance on a non-standardized tool limits comparability with existing literature and may reduce generalizability. Nevertheless, several of our items closely align with validated measures. For example, our statements \u0026ldquo;I enjoyed learning about 5Ways@School\u0026rdquo; and \u0026ldquo;I enjoyed teaching the 5Ways@School\u0026rdquo; resemble items such as \u0026ldquo;I like [INTERVENTION]\u0026rdquo; in the Acceptability of Intervention Measure (AIM) (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFinally, our qualitative data collection was restricted to teachers. Resource constraints led us to collect only quantitative data from students, but qualitative insights from students could have provided valuable perspectives on programme implementation.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur findings show that the 5Ways@School had acceptable user satisfaction among students and teachers in Grades 5\u0026ndash;7, and that the implementation fidelity among teachers was high in all grades studied. However, this high fidelity likely came at a cost: teachers noted that the guidelines provided by researchers constrained their ability to adapt the program to their students\u0026rsquo; needs, and they expressed concern about this lack of flexibility. While the programme appears feasible, it requires further development and optimisation based on feedback from students and teachers before broader implementation.\u003c/p\u003e \u003cp\u003eFurther investigation is also needed to understand why a minority of students reported negative emotional responses to the lessons, as these insights will be important for refining the programme. Future improvements to the Ways@School intervention should prioritise co‑creation of content with students and teachers, increased use of activity‑based learning, and greater flexibility to support age‑appropriate adaptation.\u003c/p\u003e \u003cp\u003eBecause user satisfaction is a key determinant of successful implementation, future work should also examine how teacher engagement can be improved, particularly among teachers in Grades 8\u0026ndash;10. Presenting teachers with research demonstrating that increased student wellbeing can support academic performance may be one strategy for strengthening engagement (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). In addition, future implementation may benefit from embedding the intervention more explicitly within the broader school curriculum, integrating the Five Ways into regular school routines over a longer period of time.\u003c/p\u003e \u003cp\u003eOverall, 5Ways@School shows promise as a teacher‑delivered, curriculum‑based intervention that can be integrated into existing educational structures to support adolescent wellbeing.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e5Ways@School\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Five Ways to Wellbeing at School Intervention\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANOVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eanalysis of variance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence Interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMANOVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emultivariate analysis of variance\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNOK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNorwegian kroner (currency)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ethematic analysis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTIDieR Checklist\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTemplate for Intervention Description and Replication Checklist\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eEthics approval was obtained from the Regional Committee for Medical and Health Research Ethics in South East Norway (reference no. 491440). Informed consent was sought from parents before students were invited to complete questionnaires. Consent for a student\u0026apos;s participation was required from at least one parent; however, if either parent expressed dissent, the student was not eligible to participate in the study. The students themselves were also required to provide informed consent and could withdraw at any time, with their data deleted unless already used in statistical analyses.\u003c/p\u003e\n\u003cp\u003eAll teachers who had taught the 5Ways@School were invited to complete a questionnaire and participate in qualitative interviews, with participation being voluntary and based on informed consent. Due to a low response rate initially, teachers were offered a chance to win one of ten NOK 1000 (\u0026asymp;90\u0026euro;) gift vouchers. Teachers could withdraw consent at any time, with their data deleted unless already used in analyses.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due to restrictions in the ethics approval obtained for this project.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eKGK is employed as Chief Medical Officer at Moss Municipality, where the study was carried out. The authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis project was funded by Moss Municipality, Norwegian Institute of Public Health, PROMENTA research centre, University of Oslo, the County Governor of Oslo and Viken, and the Norwegian Research Council (project no. 345560 and 288083). The study was designed and developed in dialogue with Moss Municipality.\u0026nbsp;The County Governor and the Research Council had no role in the research process.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eKGK designed the study, conducted the analyses and wrote the paper; EB, NOL, RRC, and RBN designed the study and revised the paper.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors wish to thank all participating students, teachers, and school leaders in Moss and R\u0026aring;de municipalities. We also want to thank the Norwegian Council for Mental Health and Skolerom Publishing House for collaborating with us on this project, and Professor \u0026Aring;shild Lappegard Hauge for invaluable advice on qualitative methods.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSacco R, Camilleri N, Eberhardt J, Umla-Runge K, Newbury-Birch D. A systematic review and meta-analysis on the prevalence of mental disorders among children and adolescents in Europe. Eur Child Adolesc Psychiatry. 2024;33(9):2877\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarquez J, Taylor L, Boyle L, Zhou W, De Neve J-E. Child and Adolescent Well-Being: Global Trends, Challenges and Opportunities. In: Helliwell JF, Layard R, Sachs JD, De Neve J-E, Aknin LB, Wang S, editors. World Happiness Report 2024. Oxford: University of Oxford: Wellbeing Research Centre; 2024. pp. 61\u0026ndash;102.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePotrebny T, Nilsen SA, Bakken A, von Soest T, Kval\u0026oslash;y K, Samdal O, et al. Secular trends in mental health problems among young people in Norway: a review and meta-analysis. European Child \u0026amp; Adolescent Psychiatry; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaird S, Choonara S, Azzopardi PS, Banati P, Bessant J, Biermann O, et al. A call to action: the second Lancet Commission on adolescent health and wellbeing. Lancet. 2025;405(10493):1945\u0026ndash;2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohan A, Kostelecky SM, Sivakumar A, Khalil M, Clark H. Improving adolescent wellbeing is an urgent global priority. BMJ. 2022;379:o2551.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Division of Mental Health. Life skills education for children and adolescents in schools. Pt. 1, Introduction to life skills for psychosocial competence. Pt. 2, Guidelines to facilitate the development and implementation of life skills programmes. Geneva; 1994 1994. Report No.: WHO/MNH/PSF/93.7A.Rev.2 Contract No.: WHO/MNH/PSF/93.7A.Rev.2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen KA, Ito S, Ahuvia IL, Yang Y, Zhang Y, Renshaw TL et al. Brief School-Based Interventions Targeting Student Mental Health or Well-Being: A Systematic Review and Meta-Analysis. Clinical Child and Family Psychology Review. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartinsen KD, Rasmussen LMP, Wentzel-Larsen T, Holen S, Sund AM, L\u0026oslash;vaas MES, et al. Prevention of anxiety and depression in school children: Effectiveness of the transdiagnostic EMOTION program. J Consult Clin Psychol. 2019;87(2):212\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLawson GM, Orapallo A, Ginsburg GS, Brewton A, Baker CN, Azad G. Teacher-Delivered Mental Health Interventions: Promises, Challenges, and Recommendations for Future Directions. 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Universal Wellbeing Practices in Schools: Framing Evidence-Informed Practice Within the Five Ways to Wellbeing. Educational Psychol Res Pract. 2021(7 (1)):1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMackay L, Egli V, Booker LJ, Prendergast K. New Zealand's engagement with the Five Ways to Wellbeing: evidence from a large cross-sectional survey. Kotuitui. 2019;14(2):230\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrydz MB, Bj\u0026oslash;rndal LD, Czajkowski NO, R\u0026oslash;ysamb E, Nes RB. Direct and indirect effects of a digital Five Ways to Wellbeing intervention: A network intervention analysis. Behav Res Ther. 2025;191:104781.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrydz MB, Czajkowski NO, R\u0026oslash;ysamb E, Rodr\u0026iacute;guez-Cano R, Nes RB. Exploring Mechanisms in a Digital Five Ways to Wellbeing Intervention: A Multilevel Mediation Analysis. SSRN Preprint [Internet]. 2025 2025-08-05. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ssrn.com/abstract=5357441\u003c/span\u003e\u003cspan address=\"https://ssrn.com/abstract=5357441\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchultes M-T. An introduction to implementation evaluation of school-based interventions. Eur J Dev Psychol. 2023;20(1):189\u0026ndash;201.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDurlak JA, DuPre EP. Implementation Matters: A Review of Research on the Influence of Implementation on Program Outcomes and the Factors Affecting Implementation. Am J Community Psychol. 2008;41(3):327\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCurran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50(3):217\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlley ZM, Chapman JE, Schaper H, Saldana L. The relative value of Pre-Implementation stages for successful implementation of evidence-informed programs. Implement Sci. 2023;18(1):30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10(1):53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReardon CM, Damschroder LJ, Ashcraft LE, Kerins C, Bachrach RL, Nevedal AL, et al. The Consolidated Framework for Implementation Research (CFIR) User Guide: a five-step guide for conducting implementation research using the framework. Implement Sci. 2025;20(1):39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrogshus KG, Bjertness E, Czajkowski NO, Rodriguez-Cano R, Nes RB. Study protocol for 5Ways@School \u0026ndash; An implementation and effectiveness trial of a school-based wellbeing intervention in 16 schools in Norway. Scand J Public Health.0(0):14034948251370109.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEilertsen MN. Ragnhild Bang. Improving Wellbeing, Health and Work Adherence Effects of the 5 Ways to Wellbeing Course ClinicalTrials.gov: U.S. National Library of Medicine; 2020 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://clinicaltrials.gov/ct2/show/NCT04668560\u003c/span\u003e\u003cspan address=\"https://clinicaltrials.gov/ct2/show/NCT04668560\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrydz MB, Czajkowski NO, Eilertsen M, R\u0026oslash;ysamb E, Nes RB. A Web-Based Intervention Using Five Ways to Wellbeing to Promote Well-Being and Mental Health: Randomized Controlled Trial. JMIR Ment Health. 2024;11:e49050.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCurrie CE, Elton RA, Todd J, Platt S. Indicators of socioeconomic status for adolescents: the WHO Health Behaviour in School-aged Children Survey. Health Educ Res. 1997;12(3):385\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCurrie C, Molcho M, Boyce W, Holstein B, Torsheim T, Richter M. Researching health inequalities in adolescents: the development of the Health Behaviour in School-Aged Children (HBSC) family affluence scale. Soc Sci Med. 2008;66(6):1429\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eR Core Team. R: A Language and Environment for Statistical Computing. 4.2.3 ed. Vienna, Austria: R Foundation for Statistical Computing; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePosit team. RStudio: Integrated Development Environment for R. 2023.03.1.446 ed. Boston, MA: Posit Software, PBC; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCurran PG. Methods for the detection of carelessly invalid responses in survey data. J Exp Soc Psychol. 2016;66:4\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eColtman T, Devinney TM, Midgley DF, Venaik S. Formative versus reflective measurement models: Two applications of formative measurement. J Bus Res. 2008;61(12):1250\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Thematic analysis: a practical guide. Los Angeles, California: SAGE; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, N. J: Laurence Erlbaum; 1988.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDamschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4(1):50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUngdatasenteret U. 2025: Moss kommune - Hovedrapport for ungdomstrinnet. Oslo: Velferdsforskningsinstituttet NOVA; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUngdatasenteret. Ungdata junior 2025: Moss kommune - Hovedrapport for mellomtrinnet 5. \u0026ndash;\u0026thinsp;7. klasse. Oslo: Velferdsforskningsinstituttet NOVA; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOECD. Unlocking High-Quality Teaching. Paris; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeslauriers L, McCarty LS, Miller K, Callaghan K, Kestin G. Measuring actual learning versus feeling of learning in response to being actively engaged in the classroom. Proceedings of the National Academy of Sciences. 2019;116(39):19251\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBećirović S. Challenges and Barriers for Effective Integration of Technologies into Teaching and Learning. SpringerBriefs in Education. Singapore: Singapore: Springer; 2023. pp. 123\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHudson KG, Lawton R, Hugh-Jones S. Factors affecting the implementation of a whole school mindfulness program: a qualitative study using the consolidated framework for implementation research. BMC Health Serv Res. 2020;20(1):133.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcLoughlin GM, Sweeney R, Liechty L, Lee JA, Rosenkranz RR, Welk GJ. Evaluation of a Large-Scale School Wellness Intervention Through the Consolidated Framework for Implementation Research (CFIR): Implications for Dissemination and Sustainability. Front Health Serv. 2022;Volume 2\u0026ndash;2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOECD. An implementation framework for effective change in schools. Paris; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):108.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaya M, Erdem C. Students\u0026rsquo; Well-Being and Academic Achievement: A Meta-Analysis Study. Child Indic Res. 2021;14(5):1743\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Mental health promotion, universal school prevention, wellbeing","lastPublishedDoi":"10.21203/rs.3.rs-8926279/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8926279/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe decline in adolescents’ mental health and wellbeing call for effective action, and teacher-delivered health promoting interventions represent a cost-effective approach with potential for universal reach. The \u003cem\u003eFive Ways to Wellbeing\u003c/em\u003e framework has demonstrated effectiveness among adults but has not previously been implemented with children or adolescents. We adapted this framework into a school-based intervention called Five Ways to Wellbeing at School (5Ways@School) and implemented it in 16 schools with 3,324 students aged 10–16 years in Moss municipality, Norway. In this paper, we examine the implementation process and discuss how the intervention can be optimised for future use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe \u003cem\u003e5Ways@School\u003c/em\u003e study employed a hybrid effectiveness-implementation design using a mixed methods approach. Data were collected through web-based questionnaires completed by students and teachers, supplemented by qualitative interviews with teachers, spanning November 2023 to December 2024. The study was longitudinal, two-armed, and non-randomised, with the intervention first administered to half of the students, while the remaining students served as a control group before receiving the intervention seven weeks later. This paper presents results based on questionnaires from 2,226 students and 113 teachers, analysed using descriptive statistics, analyses of variance (ANOVA), t-tests, and linear regression. Qualitative data from teachers’ free-text responses were analysed using thematic analysis (TA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUser satisfaction with the intervention was moderate among students and teachers in Grades 5–7 but lower in Grades 8–10, particularly among teachers. Implementation fidelity was high across all grade levels. Teacher feedback indicated a need for greater flexibility to adapt the programme to classroom contexts, more age‑appropriate adjustments, and increased use of activity‑based learning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 5Ways@School programme is feasible but requires further refinement to enhance flexibility, support age‑appropriate adaptation, and incorporate more activity‑based content. Improving teacher engagement—especially in Grades 8–10—and more explicitly integrating the Five Ways into the broader school curriculum will be important for successful future implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegistry\u003c/strong\u003e: ClinicalTrials.gov, TRN: NCT06144502, Registration date: 16 November 2023.\u003c/p\u003e","manuscriptTitle":"The implementation of the Five Ways to Wellbeing innovation in 16 Norwegian schools: Lessons learned and future directions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 14:10:06","doi":"10.21203/rs.3.rs-8926279/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cf07973b-7f23-4fae-83f5-8f98ace4d862","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-27T14:10:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 14:10:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8926279","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8926279","identity":"rs-8926279","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}