Visualizing potential contextual influences in and across complex settings: a qualitative study on structured school health promotion implementation

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Enhancing schools’ ability to manage change processes—e.g. through a plan-do-study-act (PDSA) cycle—has been identified as a promising capacity-building approach. However, contextual conditions at individual schools may influence the utilization of the PDSA cycle for HPA implementation. Understanding this influence is critical to determine whether tailored approaches are needed or whether the PDSA cycle can serve as a generalizable, effective strategy. This study aimed to investigate whether, which, and how contextual factors determine the application of the PDSA cycle for HPA implementation and to reflect on the methodological approach’s value for implementation research. Methods The study was part of an evaluation of a large-scale school health promotion program designed to build capacity through teaching the PDSA cycle. We combined qualitative interviews with representatives from nine schools with matrix heat mapping to visualize contextual factors influencing the perceived implementability of HPA using the PDSA cycle. Schools were compared to identify commonalities, differences, and determinant patterns. Results School representatives reported various contextual factors potentially influencing PDSA cycle utilization for future HPA implementation. Schools with prior experience using structured, PDSA-cycle-like processes perceived fewer contextual barriers and more facilitators, suggesting either the effectiveness of a structured approach or the necessity of certain contextual facilitators. Supportive communication structures, sufficient financial means, and space emerged as potential consequences of using structured processes or prerequisites for PDSA cycle use. Although lack of parental engagement, work infrastructure barriers, and time constraints were reported across nearly all schools, they did not inhibit some from applying structured processes. Conclusion Contextual factors shape the implementability of the PDSA cycle for HPA in schools. Whether these factors are prerequisites or can be shifted through applying the PDSA cycle remains unclear. Our study offers a methodological approach to examine implementation context in complex, multi-site settings. This approach may help identify determinant patterns and inform the broader debate on generalizability versus context-specificity in implementation research. Future studies should test this approach in larger, more diverse samples to guide strategy selection and inform scaling efforts. School Health Promotion Capacity-Building PDSA cycle Implementation Context Generalizability Matrix Heat Map Data Visualization Systems Thinking Figures Figure 1 Contributions to the literature Structured approaches like the PDSA cycle are increasingly promoted to build capacity for school health promotion implementation, yet their application may be shaped by and shape contextual factors at the school level. This study advances matrix heat mapping as a method to systematically compare perceived implementation barriers and facilitators across multiple sites while managing contextual complexity. By identifying a potential pattern of key contextual factors, our findings contribute to the debate on generalization versus context-specific adaptation in implementation research and offer a transferable approach to support strategy development across complex settings. Background Transforming the environments where we live, learn, and work into health promoting settings has been a central goal for health professionals since the World Health Organization's (WHO) Ottawa Charter was published in 1986 ( 1 ). Given that good health and healthy behaviors early in life are linked to better health throughout the lifespan, focusing on the settings where children live and learn is crucial from a health promotion perspective ( 2 , 3 ). Schools offer a key opportunity for impactful health promotion and the advancement of health equity, as they are established and accessible platforms providing the structures to engage with a great number of children, regardless of socioeconomic factors or cultural and political background ( 4 – 6 ). Research shows that holistic school health promotion, following the health promoting school (HPS) framework proposed by the WHO, can bring about sustainable and equitable health outcomes ( 7 , 8 ). The HPS framework encompasses the implementation of interventions targeting individual determinants, but more so the creation of a healthy school environment that enables the school community to engage in health-promoting behaviors and the strengthening of health-promoting community connections outside of school ( 9 ). Today, a HPS, is characterized as a school “that constantly strengthens its capacity as a healthy setting for living, learning and working” ( 10 ). Thereby, strengthening or building capacity refers to the process of developing and enhancing the abilities, resources, and structures necessary for schools to effectively implement and sustain health promoting activities (HPA). This involves creating an environment where health promotion is integrated into the school's core functions and management processes ( 11 ). Despite the promising evidence that HPS improve health and educational outcomes and the ongoing wish by the WHO to “make every school a health-promoting school” ( 12 ), the HPS landscape remains rather uncoordinated and fragmented, as most schools implement intervention after intervention without ever building capacity on organizational level, which results in so-called “projectitis” and a burden on both human and financial resources ( 13 – 15 , 4 ). Accordingly, there is a need to support schools in building their capacity for health promotion ( 4 , 16 ). One promising approach for building schools’ capacity is training them how to design and manage change processes effectively ( 4 , 17 – 19 ). For instance, the Schools for Health in Europe Network Foundation (SHE) has published a manual outlining how schools can become a HPS by applying a cyclical process of planning, doing, studying, and acting—commonly known as the Deming or PDSA cycle ( 20 , 19 ). In Germany, the national Guideline for Prevention and Health Promotion also recommends integrating the PDSA cycle into setting-based interventions in order to facilitate building capacity ( 21 ). Despite its widespread promotion, there is limited empirical evidence on the effectiveness of utilizing the PDSA cycle in driving actual practice change within schools ( 16 ). Moreover, contextual factors such as leadership support, work infrastructure, and time play a crucial role in both school improvement and school health promotion implementation implicating that these factors might also shape how schools can use the PDSA cycle for implementing HPA ( 22 – 25 ). Based on these insights, we raise the question of which contextual factors at individual schools influence the use of PDSA cycles for implementing HPA. Further, we aim to contribute to the ongoing debate on context-specificity and generalizability in implementation research ( 26 , 27 ). To do so, we will compare the contextual factors at individual sites, identifying both commonalities and differences. Additionally, we will explore whether a pattern emerges that could inform the tailoring of additional strategies needed to support the implementation and sustainment of HPA, alongside the utilization of the PDSA cycle. As schools, similar to other implementation settings, are complex organizations, an increasing number of researchers advocate for adopting a systems thinking perspective for research endeavors ( 28 , 13 , 29 ). Systems thinking is conceptual and involves thought patterns such as distinguishing between parts of the system (e.g. characterizing contextual factors), understanding the relationships between these parts and how they form the system (e.g. investigating the interplay between these factors) and giving importance to perspective (e.g. through methodological considerations) ( 30 ). Such conceptual thinking that “embrace[s] uncertainty, non-linearity, local variability and emergent characteristics holds promise for re-examining the challenges to health-promoting schools" and other implementation challenges ( 29 ). While studies considering the complexity within and across schools are scarce, Salvati et al. pioneered such a research approach by comparing contextual factors as determinants across different organizational units regarding a new intervention to be implemented in the healthcare context ( 31 ). They conducted interviews on the experienced determinants at the individual sites, and visualized their results using a matrix heat map (MHM). Through this approach, they were able to uncover potential difference-makers, which are the key determinants that are most likely relevant for implementation success or failure. Moreover, they were able to make better sense of the complexity of determinants within and across units. Transferring this approach might be valuable to better understand whether and how contextual factors impact the utilization of PDSA cycles for the ongoing implementation and sustainment of HPA. Further, testing the approach in a non-clinical setting might underscore its value for more than one implementation field. Under the premise of a systems thinking perspective, the aims of this paper are therefore to identify the contextual factors that are perceived as key determinants to the utilization of the PDSA cycle for implementing HPA in the future by all schools, to identify the contextual factors that differ in their perceived impact as barriers from school to school to explore and discuss how these factors might interact within schools and possibly form a pattern across schools, And to discuss the value of the methodological approach for implementation research regarding the debate on context-specificity versus generalizability. Methods Study setting Data for this study were collected in December 2023 and January 2024 as part of the implementation evaluation of a holistic school health promotion program in German primary schools (three cohorts with 300 schools each). The program encompasses individual-level and organizational level HPA as well as capacity-building components. An example of individual HPA is the provision of teaching materials on nutrition to be used by the teachers in class. An example of an organizational HPA is the provision of equipment for physical activity to be handed out to the pupils. However, capacity-building is the program’s primary focus. Schools are trained to apply a structured PDSA cycle for their HPA (that they select), now and in the future. At the program’s start, a so-called steering group has to be established at each school, involving the principal, two teachers and a parent representative. Their task is to lead the implementation and change process. Throughout this process, schools are supported through implementation strategies such as trainings, counseling with individual contact persons, get-together meetings, and materials. After two years, the aim is that schools are able to conduct HPA on their own following the PDSA cycle in a structured way. All participating schools are offered the same program content and implementation support, regardless of individual school context. Ethics approval was obtained for all data collection procedures of this evaluation project from the ethical committee of the Technical University of Munich (2023-12-NM-KH). Positionality, Ontological and Epistemological Positioning, Rigorous Reporting The lead researcher, KS, a 28-year-old woman who grew up and went to school in Germany, has prior experience in qualitative research, particularly the framework method (32) and thematic analysis (33). Other researchers involved in data collection or analysis (SB, MS, DC) also have qualitative research experience. We adopted a critical realist ontology, aligned with our research goals and methodology, and contextualism as our epistemology, assuming an objective reality that is perceived and constructed contextually (34). To ensure rigorous reporting, we follow the standards for reporting qualitative research (SRQR) (Additional File 1) (35). Sampling We selected primary schools from cohort two (intervention on-boarding in late fall 2023) following the purposeful maximum heterogeneity sampling approach by Patton et al. in order to represent the cohort as best as possible (36). Factors considered for sampling were urban or rural area, socio-economic index and federal state, as the educational systems slightly differ between the federal states in Germany. The aim was to include one school per federal state. A sample was drawn, which resulted in N=16 schools, 50% of them located in urban areas, and 50% from lower socio-economic index areas. The sampled schools were contacted via email and informed about the planned study procedure. After successful consent, an appointment was scheduled for either online or on-site data collection, depending on the school's preference. Data collection and analysis To obtain in-depth insights without making steering groups feel monitored, we conducted qualitative semi-structured group interviews in a workshop format (37). We positioned participants as experts and ourselves as learners to emphasize the importance of their perspectives. To ensure comparability with existing literature, the interview guide was based on the CFIR (38, 39), widely used to categorize implementation determinant as barriers and facilitators. The framework comprises five domains (Innovation, Inner Setting, Outer Setting, Individual, and Process) with a total of 39 constructs as well as implementation outcomes (40). In consultation with the research team, we selected relevant constructs and excluded the Innovation Domain (as it pertains to the intervention itself) (41) and the Process Domain (as data collection occurred at the program’s onset). For the same reason, implementability was used when eliciting possible barriers and facilitators to the utilization of the PDSA cycle. Damschroder et al. define implementability as “the likelihood the innovation will be put in place or delivered”, thus a forward-looking concept (40). Interviewees were therefore asked to name barriers and facilitators that they think will impact the successful utilization of the PDSA cycle to HPA implementation in the future. Given that prior experience with PDSA cycle-like processes may be an important determinant of successful implementation of future HPA (25), we also asked interviewees about the extent to which the implementation of HPA has already been approached using a structured process, similar to the PDSA cycle. The workshop format was set up to work both on-site as well as online, was conducted by two researchers (always KS with another person who took field notes) and all interviews were recorded. A detailed description of the workshop format is provided in Additional File 2. For the management and data analysis procedure, the framework method with its seven steps was chosen as a suitable methodological guideline, aligning with Salvati et al.’s approach and our ontological and epistemological position (32). The framework methodis particularly suitable for the aims of comparing contextual factors across schools and identifying potential patterns, based on qualitative data gathered through interviews (32). Although iterative this method included the following steps: (1) Transcription & (2) Familiarization with the interviews All interviews were transcribed verbatim in the same format, pseudonymized, and KS and MS familiarized themselves with the interviews and the field notes. (3) Coding First, a relatively unspecified version of the updated CFIR was used as a codebook to test-code three interviews by hand. During this process, the researchers (KS and MS) took notes about ambiguities in the coding, extended it through inductively derived categories, merged some categories and revised the codebook. In a second round, the adapted codebook was tested again with the same three interviews and further adaptations were made until all ambiguities in coding were removed. (4) Developing a working analytical framework & (5) Applying the analytical framework The codebook, as well as the adaptation steps are documented in the Additional File 3. For the final coding, the codebook and all transcripts were uploaded to MAXQDA 2020 (42), a software facilitating qualitative research. All transcripts were double-coded by two researchers (KS and MS) following the codebook, and valences were assigned whether a context factor was perceived as facilitator (positive), as barrier (negative) or as mixed (39, 31). All conflicts were resolved through discussion. (6) Charting data into the framework matrix Spreadsheets were created for each school with CFIR domains and constructs on the x-axis and all quotes imported from MAXQDA 2020 (42). Thereby, one construct could be represented by one or multiple quotes per interview. Valence ratings were assigned color codes and the cell with the quotation was colored accordingly: facilitators in blue, barriers in red and mixed factors in purple. If, for example, a quote was that the schoolyard offers a lot of space for the implementation of movement offers , this quote would be inserted into the Inner Setting/Space column and, as a facilitator, colored blue. A mixed rating, colored purple, could either come from two or more contrasting statements in one construct or one statement, which includes a contrast in itself (e.g. some teachers are really motivated, others don’t care at all in the Individual Domain/Teachers) . Next, all valence ratings per construct were aggregated into a final rating based on the following scheme: Blue only = blue = positive Blue AND purple only (no red) = blue/purple = mixed positive Blue AND red (AND purple) = purple = mixed Purple only = purple = mixed Red AND purple only (no blue) = red/purple = mixed negative Red only = red = negative Grey = neutral, not mentioned For prior experience with a structured process such as the PDSA cycle, we initially expected the responses to be categorized similarly to the other factors. However, the responses turned out to be dichotomous, with schools reporting either having or lacking prior experience with the use of structured processes like PDSA cycles. Consequently, we used blue to indicate prior experience (present) and red to indicate no prior experience (absent). This procedure was repeated for each school, generating individual spreadsheets with final valence ratings. Another spreadsheet with constructs on the x-axis and schools on the y-axis was then created, where all ratings were imported and merged into a Matrix Heat Map (MHM) for cross-school comparison. (7) Interpreting the data Both the in-depth insights from the interviews and the visualization in the MHM were evaluated and compared across schools by the principal researcher and DC in order to address the research aims. Results Sample Of the sampled 16 schools, nine schools with a total of 20 representatives, agreed to participate in the study. Table 1 gives an overview of the characteristics of the participating schools. Table 1 School Characteristics School Federal State Urban/Rural¹ Socio-economic index² # of Students Interview format # of Representatives & Roles A Berlin Urban 1 422 Online 2 Principal, School psychologist B Bavaria Urban 1 161 On-site 2 Principal, Teacher C Bavaria Rural 0 205 On-site 2 Teachers D Baden-Württemberg Rural 0 60 On-site 3 Principal, Teachers E Saxony-Anhalt Rural 0 176 Online 1 Teacher F Brandenburg Rural 1 450 Online 3 Principal, Parent, Teacher G Rhineland-Palatinate Urban 0 68 Online 2 Principal, Teacher H Saarland Urban 0 191 Online 2 Teacher I Hesse Urban 1 380 On-site 3 Teacher, Parents Note. Schools provided information on federal state and number of students upon registration for the program. ¹Based on data by the Federal Institute on Building, Urban Affairs and Spatial Development, 2021. ²Based on data by the SINUS-Institute. Contextual Factors and Matrix Heat Mapping In the interviews, 15 factors were mentioned across the Outer, Inner Setting, and Individual Domains plus prior experience with the PDSA cycle or a similar, structured process. The MHM (see Fig. 1) illustrates that some factors were universally perceived as barriers or facilitators while others varied. First, we report commonalities, the factors that have the same valence for all schools, followed by differing factors and finally, we elaborate on a potential pattern. Table 2 – 5 present exemplary quotes (Q1 – Q59) to illustrate the valence coding and highlight factor interactions. Table 2 Commonalities Across Schools Domain Factor Valence # Quote Individuals Parent Engagement Barrier Q1 "Parents are the danger, it's not a nice thing the way they set the example for their children." (School G: 28) Q2 “So you definitely have to ask the parents, yes, you can, you can teach up to a certain point, but with the parent at home, as I said, just throwing the pizza in the oven and turning on the TV. [...] By then, everything we said at school is passé, to put it bluntly. [...] That's a very high goal, where you always get them on board and say “Guys, we can only initiate things and you have to practically end them”.” (School F: 84) Principals Facilitator Q3 “And that's why I'm so glad, that you [the principal] got this going. It's really great. Not every school does this, some just continue floating in their own comfort zone.” (School F: 128) Q4 As a school principal, I now also have the obligation to promote health (School B: 97) Steering Group Facilitator Q5 I would perhaps see it as a strength that the first step has basically been taken, that the school is prepared to engage with this topic at all. That there are teachers and parents who support this topic, i.e. that they have really opened up to tackling it. I definitely see that as an encouragement, because it's not as if someone came in from outside and said: “Well, you have to implement this now”. In a way, that was the intrinsic motivation on the part of the school. (School F: 98) Q6 I simply said that it would be a great fit and then asked around who else would like to take part and then one of my colleagues and the school management immediately agreed and then we said we'd just do it. (School I: 16) Inner Setting Tension for Change Facilitator Q8 “And I think, in general, these 4 priorities of the program are very important for us, where I have to say that we also have to work on them and not always just on the curriculum.” (School E: 49) Q9 “But I think that now that it's all on the increase, […] I think more needs to be done in this area. I think we need to do more in this area.” (School C: 147) Compatibility Facilitator Q10 “And we haven't had that at the school yet and we now have to draw up a protection concept and it [the health promotion intervention] fits in really well.” (School I: 25) Materials & Equipment Facilitator Q11 “Yes, it has to be said that we are also well equipped technically.” (School F: 20) Q12 “We also have a lot of play materials [...] and now we also have the program boxes” (School G: 44–46) Communication Facilitator Q13 “So it's also really short distances and you don't have to make an appointment with the boss to start a program, he just sits next to me and says yes. But I really think that makes things a lot easier. So the communication here in the team is easy and that's really great.” (School D: 165–166) Q14 “As far as evaluation is concerned, we are actually in a good position. We have our own school app and we use it to carry out regular evaluations.” (School A: 39) Mission Alignment & Culture Facilitator Q15 “We have already won two awards [...]. And we now want to put the whole thing together into a complete package [...]. And that's actually how we came to say that this is actually the right puzzle to complete the picture.” ( School B: 9) Note. Exemplary quotes from the interviews. Commonalities across schools Parent engagement was reported as an important barrier by all schools. The school representatives felt like they cannot achieve as much when parents are not involved or even act counterproductively to the health promotion efforts (Table 2 – Q1). Bringing the parents on board was a metaphor frequently used, however doing so was challenging for all schools (Table 2 – Q2). Conversely, Principal support and engagement from Steering Group members were reported as facilitators across all schools (Table 2 – Q3-Q6). Further universal facilitators were Tension for Change and Compatibility , as well as sufficient Materials & Equipment . Tension for Change was given at all schools, as they described different health needs as the drivers for participation (Table 2 – Q8, Q9). Compatibility of program components with existing HPA already implemented at the school was also described as mostly a facilitator (Table 2 - Q10) as well as having enough Materials & Equipment to implement HPA (Table 2 – Q11, Q12). Two additional Inner Setting factors were exclusively reported as facilitators, though only about half of the schools mentioned them. The first, Relational Communications , refers to the extent to which communication structures within the school support the future implementation of HPA through utilizing the PDSA cycle, as illustrated in Q13 and Q14 in Table 2 . The second, Mission Alignment & Culture , reflects the alignment between PDSA cycle utilization for HPA implementation with the school’s mission and culture (Table 2 – Q15). Differences across schools Teacher Engagement was perceived as mixed barrier and facilitator by most schools because some but not all teachers were reported to be supportive (Table 3 – Q17). However, some schools report having committed teachers only (Table 3 – Q18), while others struggle with stronger skepticism among their group of colleagues (Table 3 – Q16). Another rather strong barrier, reported by almost all schools, with one exception, seems to be Relative Priority & Time . The schools mostly reported limited time next to the requirements from the curriculum as a barrier (Table 3 – Q19-Q21). However, one school emphasized that integrating HPA into the curriculum could mitigate this issue (Table 3 – Q22). Work Infrastructure comprises statements regarding the structural organization, e.g. full-day school or not, and how that plays out as a facilitator or barrier, but also regarding the staff level. Some schools feel like not being a full-day school limits their opportunities for future implementation of HPA (Table 3 - Q23). In turn, others report being a full-day school as a facilitator to incorporate HPA into daily routines (Table 3 - Q26). Regarding staff levels, some schools reported having enough teachers (in relation to the number students), but too few other personnel to support structured HPA implementation at the schools, resulting in a mixed rating (Table 3 - Q25). Others do have exactly this additional staff in the form of school psychologists or social workers, thus reporting staffing as a facilitator (Table 3 – Q27). Schools lacking both teachers and additional personnel cited this as a barrier (Table 3 – Q24). Space , referring to the physical infrastructure at the schools was mentioned as an important determinant by all schools, but the anticipated impact differed greatly, with some schools perceiving their physical infrastructure as a barrier (Table 3 – Q28, Q29) and others as a facilitator (Table 3 – Q30, Q31). Table 3 Differences Across Schools Domain Factor Valence # Quote Individuals Teacher Engagement Barrier Q16 "The colleagues' skepticism is a barrier." (School E: 70) Mixed Q17 “It always depends, so some colleagues really do a lot [...] and in other classes it's less. Very different.” ( School H: 16 ) Facilitator Q28 "And also the staff [is a facilitator] —since we are all people who chose this school because of these factors [the school mission and health focus], everyone here is genuinely committed to it." ( School B: 90) Inner Setting Time & Relative Priority Barrier Q19 "These programs are well designed but simply too much alongside regular school tasks." (School D: 150) Q20 "The main thing that makes it really complicated is simply the time." (School E: 97) Q21 “So you can expand the topic endlessly, yes. But you just have to see how far, what you do. Do you take something away from the lessons and that's the thing.” ( School F: 60 ) Facilitator Q22 “Strictly speaking, you have to say that it's all there in the curriculum and you just have to be clever and realize that it's part of it.” (School B: 78) Work Infrastructure Barrier Q23 "Since we are not a full-day school, they are picked up at 1 PM, which means we don't have the option to say that we will extend activities. We really try to do this through support courses and other programs... However, much more could be done." (School H: 31) Q24 "The shortage of staff is really an issue right now, with the wave of illness and the lack of teachers […] and it’s not just affecting us but also other schools. ( School B: 92 ) Mixed Q25 "Teachers pretty well, but as I said, […] everything that is important, you need additionally.” ( School D: 179) Facilitator Q26 "I mean, we are a full-day school, and that naturally brings a different perspective on the child, where you can see that we spend a long time together here. We are finding a way to structure the lessons so that it creates a health-promoting daily routine for everyone involved." ( School B: 13) Q27 "We have a new school psychologist starting today who will really provide support." ( School F: 36) Space Barrier Q28 “Space is a big issue, big space problem. Has been an issue for over 8 years” ( School I: 65) Q29 “Well, that the school gym is not always available. [...] Yes, so the spatial conditions, that we really only ever have the classrooms or the schoolyard available and the gym is not always free” ( School E: 72) Facilitator Q30 “Yes, how are you set up there (in terms of space)?” W: “Hey great, I think it's great. […] It's mega here.” ( School D: 154–158) Q31 “We are actually very well equipped in terms of space.” (School B: 21) Outer Setting Local Conditions Barrier Q32 “The gyms are completely packed, it has to be said. This goes for other schools and clubs as well. Everything is full, which is nice, of course. But in the afternoons, for example, there are hardly any sports clubs because there’s no space. The people are available, but not the venue." ( School I: 84–85) Q33 “The schoolyard is also rented by the city and the question is who does what [...] and it's a traffic training area, so it's also a parking lot for people who go to the sports hall, so it's not separated.” KS: Ok, and they said they weren't allowed to change that either. “Yes, so most of the schoolyard has to stay like this because of the traffic signs.” ( School H: 48–50) Facilitator Q34 "We have fields and forests here—really ideal conditions." ( School G: 30) Partnerships Barrier Q35 “Even with the cafeteria, which opens during the 2nd break. They only sell crap.” ( School I: 45 ) Facilitator Q36 "We have many after-school sports groups, and we also receive some support from associations, or we have partnerships with sports clubs." ( School F: 65) Q37 "Nutrition is such that we are in close contact with the food providers; we are definitely working to promote health and collaborate closely." ( School B: 53) Financing Barrier Q38 “Financial resources, that's always somewhat of a problem ( School I: 79 ). Q39 We can, but then the question is who finances it (...). We wanted a multifunctional space like this upstairs, but it costs €20,000 and then it's always rejected.” ( School H: 50) Facilitator Q40 “So we can actually add financial resources […] that's not the problem here. So there's also something from the school board, from the side, so if I have a budget for next year, I can definitely take something from that.” ( School B: 103) Note. Exemplary quotes from the interviews. Closely related, but part of the Outer Setting domain is the factor Local Conditions , which we consolidated with the factor Policies & Laws , as it was only mentioned by one school. For example, one school viewed having a nearby forest as a facilitator (Table 3 – Q34), whereas others cited limited outdoor space (Table 3 – Q32), or a schoolyard used as a public parking lot as barriers (Table 3 – Q33). The next category, Partnerships & Connections , refers to collaborations with external organizations e.g. sports clubs. While most schools reported having supportive partnerships (Table 3 – Q36, Q37), some schools struggle with their partnerships, perceiving them as a barrier (Table 3 – Q35). The last category, Financing , was coded for any statements regarding financial resources as barriers or facilitators. Some schools perceived financing, or more often the lack of it, to be a fundamental barrier (Table 3 – Q38, Q39), while others reported to have sufficient financial resources available (Table 3 –Q40). The responses to the question about prior experience with the PDSA cycle or a similar, structured process fell into two categories and are listed in Table 4 (Q41-Q49). Either school representatives reported already working in a structured manner and having prior experience e.g. "We are, and the school leadership or the deputy principal is already very structured. And when we develop something, like a media concept, it runs very smoothly" (School C), or they reported working rather unstructured and lacking prior experience e.g. "I actually don’t see any structure in the processes yet" (School E). None of the schools indicated having fully utilized the PDSA cycle prior to the program. Table 4 Prior Experience with a Structured Approach School Structured Approach # Quote A Present Q41 “However, our overall approach to implementation is already very structured...I'll put it this way, it's constantly growing. It goes on and on.” (School A: 31) B Present Q42 “So it's already very structured, institutionalized, where I've seen that if you just do it regularly, then it just becomes second nature.” (School B: 20) C Present Q43 "We are, and the school leadership or the deputy principal is already very structured. And when we develop something, like a media concept, it runs very smoothly." (School C: 173 ) D Present Q44 “We're actually already quite far along. We recognized things and then tried to land some projects. Also with people from outside. To implement them, to evaluate them. But of course, the harvest, we're not quite there yet, it just takes time.” (School D: 124) E Absent Q45 "I actually don’t see any structure in the processes yet." (School E: 53) F Absent Q46 “It is not yet anchored in any structure” (School F: 20) “These are always just small, selective things that come up from time to time, exactly, but they don't, as they say, keep repeating themselves in a rotating loop.” (School F: 49) G Absent Q47 “I just think it's all a bit piecemeal, not structured” (School G: 21) “What we lack is evaluation. There's nothing there yet, because the other things are also a bit behind.” (School G: 32) H Absent Q48 We do a lot, but not with such a background and structured approach. (School H: 4) I Absent Q49 Again, there are so many individual aspects that count, but still no single common thread, no structure. (School I: 55) Note. Quotes from the interviews. Potential pattern Through the visualization of the contextual factors a potential pattern of interaction emerged that could not be directly traced back to any of the sampling factors. Instead, schools with a higher relative amount of anticipated contextual barriers versus anticipated contextual facilitators reported no prior experience with structured approaches such as PDSA cycles. We therefore believe this pattern is an indicator of implementability. Schools, which reported to have some structure in their HPA reported most of their contextual factors as facilitators. The opposite seemed to be true for schools, which are not yet structured in their HPA. All schools with prior experience using a structured approach (Schools A-D) reported at least some positive Relational Communications , while none of the schools without prior experience (Schools E-I) did so. Further, none of the four schools with prior experience reported Financing to be a barrier, but rather three of these reported it to be a facilitator and the other one reported financing as neutral or not salient. Finally, space was perceived as more of a barrier than facilitator by four of the five schools without prior experience, but none of those with prior experience. Some schools also reported that some contextual factors influenced others, acting as reinforcing barriers or facilitators. However, these interactions were not consistent across schools but may serve as a starting point for further exploration. One such factor was Financing . A lack thereof was mentioned as influencing Partnerships & Connections , the available Space and Work Infrastructure (School I, F, D; Table 5 – Q50-52). In turn, low staff levels ( as part of Work Infrastructure) in combination with low Relative Priority & Time was mentioned to influence Relational Communications and ultimately Parent Engagement (School I; Table 5 – Q53). Additionally, positive reinforcements were reported in some schools. For example, having a strong Mission Alignment and a health-promoting Culture was perceived as positively influencing future Teacher and even Parent Engagement in one school (School B, C; Table 5 – Q54-Q56). Further, Relational Communications , in the form of established communication structures, were perceived as positively influencing both Teacher and again Parent Engagement , as well as a conducive Work Infrastructure (School A; Table 5 – Q57-Q59). Table 5 Interactions of Factors Domain Factor Valence # Quote Outer Setting Financing & Local Conditions ◊ Partnerships & Connections Barrier Q50 “Our caterer is a disaster, a real disaster. That would be great, of course, but it's not going to happen, you can't get rid of them. [...] Yes, and because there aren't any around here who do that. And it's also a cost factor. (School I: 31–33) Outer Setting – Inner Setting Financing ◊ Space Barrier Q51 “The problem at the moment is that we don't have a school kitchen. But we're doing a charity run soon, where we want to raise money for it. Because we can only tackle the issue of nutrition if we have a functioning school kitchen where we can try things out.” (School F: 49) Outer Setting – Inner Setting Financing ◊ Work Infrastructure (Staff Level) Barrier Q52 “So if we have to get finances from external sources, then it becomes difficult, so as soon as it's somehow done through the school, then it's not a problem, but as soon as it's something bigger and people have to be hired, we reach our limits.” (School D: 175) Inner Setting – Individuals Domain Staff Level, Time ◊ Relational Communications ◊ Parent Engagement Barriers Q53 “Parents should be brought on board much more. I think this is neglected due to lack of patience, lack of time and the many sick leaves. More conversations should be held if capacity allows.” (School I: 80–83 ) Inner Setting – Individuals Domain Mission Alignment/Culture ◊ Teacher Engagement Facilitator Q54 “And also the staff, because we are all people who chose this school because of the factors, and they are all people here who want it too.” (School B: 90) Q55 “So there will be colleagues who say they don't feel like it [...] But I would say that 80% of colleagues would already be open to it. We are also a committed school here.” (School C: 317) Inner Setting – Individuals Domain Mission Alignment/Culture ◊ Parent Engagement Facilitator Q56 “The fact that they chose this school because of the concept is, of course, another driving force, [...] of course, we want it out of our own conviction, but the parents are also behind it and want to support it.” (School B: 15) Inner Setting – Individuals Domain Relational Communications ◊ Teacher and Parent Engagement Facilitator Q57 “Communication was transparent, it was also announced and presented to the entire school management. Also in the committee: that is the school management, certain teachers, educational specialists, secretaries. And they then take the information back to their areas. Since the program is also suitable for substitute teaching, the program was then briefly presented to the entire teaching staff at the general conference.” (School A: 12) Q58 “Otherwise it would be nice if there was more parental involvement and more interest. Among parents and teachers. But we are confident about that too. We have laid the groundwork, we have communicated it [...]” (School A: 14) Inner Setting – Individuals Domain Relational Communications ◊ Work Infrastructure Facilitator Q59 “We have established communication structures where we exchange information. I wanted to get away from the questionnaires, evaluating, extra work. This is how it fits into the teaching context, the daily work routine. We now have weekly situations where we exchange ideas and get feedback. (School A: 40–41) Note. Exemplary quotes from the interviews. Discussion This paper aimed to identify contextual factors that are perceived to facilitate or inhibit the future utilization of the PDSA cycle for implementing HPA, uncover differences across German primary schools, and explore how these factors interact and potentially form patterns. Taking a systems thinking perspective, we also examine these findings in relation to the debate on context-specificity versus generalizability in implementation research ( 26 , 27 ). We identified an overarching pattern whereby schools with prior experience in a structured process similar to the PDSA cycle reported more contextual facilitators, whereas those without prior experience reported more barriers. Prior experience with a structured process similar to the PDSA cycle has been shown to impact its implementation for future school improvement ( 25 ). Our findings build on and extend this by highlighting the potential role that prior experience may have in reducing perceived contextual barriers and increasing facilitators for the future utilization of the PDSA cycle for HPA implementation. We found prior experience to be associated with strong communication structures and sufficient financial support as facilitators, whereas the absence of prior experience was linked to financial constraints as a barrier and a lack of mention of communication structures as a facilitator. This raises the question of causality: Does utilizing a PDSA-cycle-like structured approach help overcome barriers, or are schools with fewer barriers and more facilitators better prepared for utilizing the PDSA cycle? Due to the cross-sectional nature of this study, we cannot establish any causal direction. However, it is worth considering whether teaching the PDSA cycle alone is sufficient to overcome barriers to its application, or if additional strategies are needed to facilitate structured HPA implementation. From a systems thinking perspective, interactions shape the system’s behavior ( 28 ). If, as in the present case, utilizing the PDSA cycle for HPA implementation is the desired behavior of the system, having well-functioning and supportive communication structures might be an important prerequisite. Teaching school personnel, particularly leadership, how to establish such communication structures might be a capacity-building strategy needed to facilitate the use of PDSA cycles for HPA implementation. Further, effective communication, cooperation, and organization might also help bring important stakeholders on board ( 43 ). Engaging stakeholders may be particularly relevant, as in Germany, the amount of budget schools receive depends on the school authorities (mainly community and partly federal state) ( 44 ). However, other stakeholders such as parent initiatives, sports clubs, and health insurance companies could provide additional funds and resources to be used for HPA in particular ( 44 ). Helping schools communicate their intention to become a HPS to these stakeholders could facilitate the acquisition of additional financial resources. Based on our case-based insights, financial resources may also impact other factors, such as space, partnerships, and work infrastructure. From a systems thinking perspective, supporting schools in acquiring more resources from stakeholders could initiate a cascade of positively reinforcing loops, gradually removing further barriers ( 45 ). Future research should investigate and model these potential interactions and feedback loops using methods such as causal loop diagramming ( 46 ). On a practical level, for schools to be able to communicate their mission to stakeholders and get them on board, there must first be clarity about the mission. In most theories on organizational change commonly used in school improvement, a clear mission plays a key role in guiding change and development ( 20 ), which was also mentioned in some cases in our data. Further, having a clear mission can guide not only the school team through the process of change but could also help get the parents on board if communicated and embodied well ( 47 – 49 ). This additionally suggests that it might be worthwhile to support schools in developing a health-centered school mission, ensuring strong commitment to it, and aligning structures and work processes accordingly, alongside teaching communication skills to build capacity. Another perspective to consider is that the PDSA cycle could technically be used for addressing all the above mentioned factors, setting up better communication structures, a mission statement and a strategy for stakeholder engagement ( 20 ). Thus, more research is needed to investigate how these factors interact and stand in causal relationships with each other in a larger sample of schools to be able identify and target the root causes more effectively. One method suitable for such an investigation is Coincidence Analysis (CNA), as it identifies configurations of factors leading to a specific outcome ( 50 ). As a preselection of factors is necessary for this method, our study has made an important contribution to such a research endeavor by narrowing down possible difference makers to use in CNA ( 31 ). Independent of prior experience, and thus presumably generally valid for German elementary school, were the barriers lack of Parent Engagement , Work Infrastructure , comprised of staff levels and school organization, and Relative Priority & Time . All schools highlighted to some degree that without Parent Engagement , they feel limited in their agency. This finding aligns with our systems thinking perspective, viewing schools as complex adaptive systems that require meaningful interactions with stakeholders, particularly parents, to achieve successful and sustainable health promotion ( 28 , 13 ). As mentioned above, a lived mission statement as well as strong communication structures might improve parent engagement according to literature ( 47 – 49 ). However, we saw this only in one school, resulting in a mixed rather than a negative rating of parent engagement. This indicates a special need to understand why parents do not engage and identify additional strategies to overcome this barrier, and it is possible that PDSA cycles will be insufficient in doing so. Regarding the Work Infrastructure construct, being organized as a full-day school naturally provides more time for HPA. Further, transitioning to a full-day school also requires capacity for implementing several profound changes on an organizational level, and as by 2026, all primary schools are technically obligated to provide full-day care, there might be synergies in change processes worth leveraging ( 51 ). Additionally, low staff levels are a systemic problem as Germany is facing a significant teacher shortage, exacerbated by high mental health burdens among educators ( 52 ). Improving teacher mental health through targeted interventions could thus be seen as another capacity-building strategy and a prerequisite for the successful application of the PDSA cycle for HPA implementation. Lastly, aligning with Scheffler et al., our results indicate that while schools intend to utilize the PDSA cycle to implement HPA, they often perceive this as unattainable due to the high demands and multiple requirements of the curriculum ( Relative Priority & Time ) ( 53 ). Framke & Sorensen suggested that, to achieve organizational change, the primary task of the organization should be at the center of each change initiative ( 54 ). The primary task of German elementary schools is “to enable basic school education in a joint educational programme for all children [with] the goal […] to acquire and extend basic and adaptable competences” ( 44 ). Program designers could focus on highlighting how the PDSA cycle can be used not only for the implementation of HPA but also for other school improvement processes that might be perceived as closer to the primary task and for integrating HPA within curricula-based activities. Overall, we aimed to contribute to the debate on context-specificity versus generalizability in implementation research. Randomly addressing contextual determinants across all sites, schools in our case, risks inefficient resource allocation while individual context assessments and tailored strategies would be equally resource-intensive and impractical ( 55 ). Our pattern-based approach offers a potential solution by focusing on the a priori identification of a set of key factors, allowing for more targeted strategy selection. This could help balance the need for context-specific tailoring with the benefits of generalizable strategies such as the PDSA cycle ( 55 ). A similar methodological approach has been used once prior to our work and has proved its benefits for implementation evaluation in the clinical setting ( 31 ). We can thus conclude that the approach is valuable in offering a way forward in regard of the context-specificity versus generalizability debate for more than one topical implementation field. This study has several strengths and limitations that should be considered. A strength is the innovative method combination and the systems thinking perspective which enabled us to understand the complexity of the matter and generate novel insights on key contextual factors, potential interactions and a pattern. However, this exploratory approach necessitates future research to generate more robust findings, as the sampling strategy and resulting small sample size may limit the generalizability of the results. Additionally, all participating schools had already decided to implement the program, which may have led to a neglect of barriers regarding the initial adoption decision. Furthermore, discussing leadership and steering group motivation and support in the presence of their members may have influenced responses due to social desirability bias. From a methodological perspective, the MHM visualization used to compare contextual factors across schools does not capture all nuances of the qualitative data, and the very open and explorative nature of the study led to gaps in the data, leaving some aspects underexplored. More targeted follow-up questions to schools could have provided deeper insights into the identified barriers and facilitators. Conclusion Our findings suggest that contextual factors shape the perceived implementability of PDSA cycles for HPA in schools. Schools with prior experience in structured change processes reported fewer anticipated barriers and more facilitators, indicating a potential link between applying structured implementation approaches and reductions in perceived challenges. However, it remains unclear whether prior experience actively reduces barriers or if schools with fewer barriers are simply better positioned to adopt structured processes. A key finding of this study is the potential role of communication structures in supporting the successful use of the PDSA cycle. Strengthening internal and stakeholder communication may assist schools without prior experience in adopting structured capacity-building strategies and potentially help mitigate other barriers for utilization such as a lack of financial support. Additionally, some barriers—such as lack of parent engagement, time, and work infrastructure—were reported across all schools, regardless of prior experience. Whether the full application of the PDSA cycle can help overcome these universal barriers or other, more specific strategies are needed remains unclear. By adopting a systems thinking perspective and applying a matrix heat mapping approach to qualitative data, our study offers a structured way to explore implementation complexity within and across school settings. This approach enabled the identification of both shared and unique contextual factors, and helped uncover a potential pattern of determinant factors linked to prior experience. As such, our method contributes to the broader debate on context-specificity versus generalizability in implementation research. It may offer a pragmatic path forward in other complex implementation settings as well. Future research should test this approach in larger, more diverse samples and examine causal relationships between contextual factors, PDSA cycle utilization, and capacity development. This may help balance tailored and generalizable strategies in school health promotion and beyond. Abbreviations CFIR Consolidated Framework for Implementation Research MHM Matrix Heat Map HPA Health-promoting activities HPS Health Promoting School PDSA cycle Plan-Do-Study-Act cycle WHO World Health Organization Declarations Ethics approval and consent to participate The ethics committee of the Technical University of Munich approved of the study prior to any data collection procedures in September 2023 ( 2023-12-NM-KH ). Consent was obtained from all participants prior to conducting the interviews. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Funding The project is funded by the health insurance company DAK Gesundheit and the planero GmbH. The funders did not have a role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authors' contributions KS was mainly in charge of the study and the writing of this manuscript. SB mainly contributed to the conceptualization of the study. Interviews were conducted by KS, supported by SB and student assistants. The codebook was developed and the interviews were coded by KS and MS. DC supported KS majorly in the creation of the MHM, the interpretation of the results and the discussion. KS wrote the manuscript with conceptual support from FM, SB and FB. SB, FM and DC commented the writing. All authors read and approved the final manuscript. Acknowledgements We express our gratitude to all school representatives for their participation. We thank our research assistants Anna Kaufmann, Philippa Winter, and Laura Eipel for their assistance in interviewing and transcribing. Availability of data and materials The pseudonymized interview data used and analyzed during the current study are available from the corresponding author on reasonable request. References WHO. 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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-6079185","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":453179740,"identity":"4645c167-e2ac-4dd0-90bc-26539f156696","order_by":0,"name":"Katharina Sterr","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9klEQVRIiWNgGAWjYBACCQYGNggFBXJgkgevFma4FsYGIGHMQ6QWBriWxB5CWiTbzx978HOPRR5/A/vzBx/33EvfL5GdwPCmArcWaZ5kdsOeZxLFEgd4DBtnPCvO7ZHI3cA45wxuLXIMyWwSPAckEhsO8DA28xxIAGth5m3Do4X/MZvkH6CW+QfYHzb/OZCQzgPW8g+PwySS2aRBtmw4wGDYzHAgIQGipQGP92c8NpOWAWrZeJjHcGbPgQTDnjNvNxyccwy3Fonzic8k3xyoS5x3vP3Bhx8HEuTZ23M3PnhTg1sLAjAjsQ8Qo2EUjIJRMApGAW4AAEBPUK3L6OkyAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0009-0004-6212-791X","institution":"Technical University of Munich: Technische Universitat Munchen","correspondingAuthor":true,"prefix":"","firstName":"Katharina","middleName":"","lastName":"Sterr","suffix":""},{"id":453179741,"identity":"a1d7ab4b-f45e-4b61-93d9-e1b018452fc9","order_by":1,"name":"Deborah Cragun","email":"","orcid":"","institution":"University of South Florida Tampa Campus: University of South Florida","correspondingAuthor":false,"prefix":"","firstName":"Deborah","middleName":"","lastName":"Cragun","suffix":""},{"id":453179742,"identity":"7913d84f-d30b-4dd2-845e-ee5e36e81fa4","order_by":2,"name":"Filip Mess","email":"","orcid":"","institution":"Technical University Munich: Technische Universitat Munchen","correspondingAuthor":false,"prefix":"","firstName":"Filip","middleName":"","lastName":"Mess","suffix":""},{"id":453179743,"identity":"1d183c46-7656-4ae6-8cd3-7e7a1636a72d","order_by":3,"name":"Friederike Butscher","email":"","orcid":"","institution":"Technical University Munich: Technische Universitat Munchen","correspondingAuthor":false,"prefix":"","firstName":"Friederike","middleName":"","lastName":"Butscher","suffix":""},{"id":453179744,"identity":"5a3594e5-4165-4517-8ee7-808e929fbe03","order_by":4,"name":"Monika Singer","email":"","orcid":"","institution":"Technical University of Munich: Technische Universitat Munchen","correspondingAuthor":false,"prefix":"","firstName":"Monika","middleName":"","lastName":"Singer","suffix":""},{"id":453179745,"identity":"1926d6ab-60f3-4d06-abd1-7ad69d2be4b2","order_by":5,"name":"Simon Blaschke","email":"","orcid":"","institution":"Technical University of Munich: Technische Universitat Munchen","correspondingAuthor":false,"prefix":"","firstName":"Simon","middleName":"","lastName":"Blaschke","suffix":""}],"badges":[],"createdAt":"2025-02-21 11:49:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6079185/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6079185/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s43058-026-00861-x","type":"published","date":"2026-01-16T16:29:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82511196,"identity":"31aeb8a2-35c7-4505-8842-a1d2687d7344","added_by":"auto","created_at":"2025-05-12 10:42:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":762391,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMatrix Heat Map\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNote. \u003c/strong\u003eThe MHM shows each individual school in a row, ordered from a) whether they reported prior experience (present at the top, absent at the bottom) and b) from schools reporting the fewest barriers (top) to schools reporting the most barriers (bottom). Each column represents a contextual factor, with the colors representing the valence rating.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6079185/v1/5c6d6c2502215bf2f896004b.png"},{"id":100617482,"identity":"62e8e758-fba4-48b8-be1e-61b9f053112a","added_by":"auto","created_at":"2026-01-19 17:53:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1790133,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6079185/v1/b6ec7313-3539-4163-980b-a85036e4a3de.pdf"},{"id":82511204,"identity":"390b66c6-3752-4592-93af-e3925de3e5bf","added_by":"auto","created_at":"2025-05-12 10:42:49","extension":"docx","order_by":10,"title":"","display":"","copyAsset":false,"role":"supplement","size":27469,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6079185/v1/f21740a3d27e3a7a28bb68f5.docx"},{"id":82511207,"identity":"d3fa52b2-1100-4e5b-bc69-be4f0f37cb23","added_by":"auto","created_at":"2025-05-12 10:42:49","extension":"docx","order_by":11,"title":"","display":"","copyAsset":false,"role":"supplement","size":20866,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6079185/v1/ba2b48119c70e33658015419.docx"},{"id":82511583,"identity":"88e49dd8-97dc-424f-ab37-2d45911964b4","added_by":"auto","created_at":"2025-05-12 10:50:49","extension":"docx","order_by":12,"title":"","display":"","copyAsset":false,"role":"supplement","size":40986,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile3.docx","url":"https://assets-eu.researchsquare.com/files/rs-6079185/v1/ccea6260fcf5030c29c4f6ff.docx"}],"financialInterests":"","formattedTitle":"Visualizing potential contextual influences in and across complex settings: a qualitative study on structured school health promotion implementation","fulltext":[{"header":"Contributions to the literature","content":"\u003cul\u003e\n \u003cli\u003eStructured approaches like the PDSA cycle are increasingly promoted to build capacity for school health promotion implementation, yet their application may be shaped by and shape contextual factors at the school level.\u003c/li\u003e\n \u003cli\u003eThis study advances matrix heat mapping as a method to systematically compare perceived implementation barriers and facilitators across multiple sites while managing contextual complexity.\u003c/li\u003e\n \u003cli\u003eBy identifying a potential pattern of key contextual factors, our findings contribute to the debate on generalization versus context-specific adaptation in implementation research and offer a transferable approach to support strategy development across complex settings.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003eTransforming the environments where we live, learn, and work into health promoting settings has been a central goal for health professionals since the World Health Organization's (WHO) \u003cem\u003eOttawa Charter\u003c/em\u003e was published in 1986 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Given that good health and healthy behaviors early in life are linked to better health throughout the lifespan, focusing on the settings where children live and learn is crucial from a health promotion perspective (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Schools offer a key opportunity for impactful health promotion and the advancement of health equity, as they are established and accessible platforms providing the structures to engage with a great number of children, regardless of socioeconomic factors or cultural and political background (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eResearch shows that holistic school health promotion, following the health promoting school (HPS) framework proposed by the WHO, can bring about sustainable and equitable health outcomes (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The HPS framework encompasses the implementation of interventions targeting individual determinants, but more so the creation of a healthy school environment that enables the school community to engage in health-promoting behaviors and the strengthening of health-promoting community connections outside of school (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Today, a HPS, is characterized as a school \u0026ldquo;that constantly strengthens its capacity as a healthy setting for living, learning and working\u0026rdquo; (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Thereby, strengthening or building capacity refers to the process of developing and enhancing the abilities, resources, and structures necessary for schools to effectively implement and sustain health promoting activities (HPA). This involves creating an environment where health promotion is integrated into the school's core functions and management processes (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the promising evidence that HPS improve health and educational outcomes and the ongoing wish by the WHO to \u0026ldquo;make every school a health-promoting school\u0026rdquo; (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), the HPS landscape remains rather uncoordinated and fragmented, as most schools implement intervention after intervention without ever building capacity on organizational level, which results in so-called \u0026ldquo;projectitis\u0026rdquo; and a burden on both human and financial resources (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Accordingly, there is a need to support schools in building their capacity for health promotion (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne promising approach for building schools\u0026rsquo; capacity is training them how to design and manage change processes effectively (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). For instance, the Schools for Health in Europe Network Foundation (SHE) has published a manual outlining how schools can become a HPS by applying a cyclical process of planning, doing, studying, and acting\u0026mdash;commonly known as the Deming or PDSA cycle (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In Germany, the national Guideline for Prevention and Health Promotion also recommends integrating the PDSA cycle into setting-based interventions in order to facilitate building capacity (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite its widespread promotion, there is limited empirical evidence on the effectiveness of utilizing the PDSA cycle in driving actual practice change within schools (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Moreover, contextual factors such as leadership support, work infrastructure, and time play a crucial role in both school improvement and school health promotion implementation implicating that these factors might also shape how schools can use the PDSA cycle for implementing HPA (\u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Based on these insights, we raise the question of which contextual factors at individual schools influence the use of PDSA cycles for implementing HPA. Further, we aim to contribute to the ongoing debate on context-specificity and generalizability in implementation research (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). To do so, we will compare the contextual factors at individual sites, identifying both commonalities and differences. Additionally, we will explore whether a pattern emerges that could inform the tailoring of additional strategies needed to support the implementation and sustainment of HPA, alongside the utilization of the PDSA cycle.\u003c/p\u003e \u003cp\u003eAs schools, similar to other implementation settings, are complex organizations, an increasing number of researchers advocate for adopting a systems thinking perspective for research endeavors (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Systems thinking is conceptual and involves thought patterns such as distinguishing between parts of the system (e.g. characterizing contextual factors), understanding the relationships between these parts and how they form the system (e.g. investigating the interplay between these factors) and giving importance to perspective (e.g. through methodological considerations) (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Such conceptual thinking that \u0026ldquo;embrace[s] uncertainty, non-linearity, local variability and emergent characteristics holds promise for re-examining the challenges to health-promoting schools\" and other implementation challenges (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile studies considering the complexity within and across schools are scarce, Salvati et al. pioneered such a research approach by comparing contextual factors as determinants across different organizational units regarding a new intervention to be implemented in the healthcare context (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). They conducted interviews on the experienced determinants at the individual sites, and visualized their results using a matrix heat map (MHM). Through this approach, they were able to uncover potential difference-makers, which are the key determinants that are most likely relevant for implementation success or failure. Moreover, they were able to make better sense of the complexity of determinants within and across units.\u003c/p\u003e \u003cp\u003eTransferring this approach might be valuable to better understand whether and how contextual factors impact the utilization of PDSA cycles for the ongoing implementation and sustainment of HPA. Further, testing the approach in a non-clinical setting might underscore its value for more than one implementation field. Under the premise of a systems thinking perspective, the aims of this paper are therefore\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eto identify the contextual factors that are perceived as key determinants to the utilization of the PDSA cycle for implementing HPA in the future by all schools,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eto identify the contextual factors that differ in their perceived impact as barriers from school to school\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eto explore and discuss how these factors might interact within schools and possibly form a pattern across schools,\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAnd to discuss the value of the methodological approach for implementation research regarding the debate on context-specificity versus generalizability.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eStudy setting\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData for this study were collected in December 2023 and January 2024 as part of the implementation evaluation of a holistic school health promotion program in German primary schools (three cohorts with 300 schools each). The program encompasses individual-level and organizational level HPA as well as capacity-building components. An example of individual HPA is the provision of teaching materials on nutrition to be used by the teachers in class. An example of an organizational HPA is the provision of equipment for physical activity to be handed out to the pupils. However, capacity-building is the program’s primary focus. Schools are trained to apply a structured PDSA cycle for their HPA (that they select), now and in the future. At the program’s start, a so-called steering group has to be established at each school, involving the principal, two teachers and a parent representative. Their task is to lead the implementation and change process. Throughout this process, schools are supported through implementation strategies such as trainings, counseling with individual contact persons, get-together meetings, and materials. After two years, the aim is that schools are able to conduct HPA on their own following the PDSA cycle in a structured way. All participating schools are offered the same program content and implementation support, regardless of individual school context. Ethics approval was obtained for all data collection procedures of this evaluation project from the ethical committee of the Technical University of Munich (2023-12-NM-KH).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePositionality, Ontological and Epistemological Positioning, Rigorous Reporting\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe lead researcher, KS, a 28-year-old woman who grew up and went to school in Germany, has prior experience in qualitative research, particularly the framework method (32) and thematic analysis (33). Other researchers involved in data collection or analysis (SB, MS, DC) also have qualitative research experience. We adopted a critical realist ontology, aligned with our research goals and methodology, and contextualism as our epistemology, assuming an objective reality that is perceived and constructed contextually (34). To ensure rigorous reporting, we follow the standards for reporting qualitative research (SRQR) (Additional File 1) (35).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSampling\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe selected primary schools from cohort two (intervention on-boarding in late fall 2023) following the purposeful maximum heterogeneity sampling approach by Patton et al. in order to represent the cohort as best as possible (36). Factors considered for sampling were urban or rural area, socio-economic index and federal state, as the educational systems slightly differ between the federal states in Germany. The aim was to include one school per federal state. A sample was drawn, which resulted in N=16 schools, 50% of them located in urban areas, and 50% from lower socio-economic index areas. The sampled schools were contacted via email and informed about the planned study procedure. After successful consent, an appointment was scheduled for either online or on-site data collection, depending on the school's preference.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData collection and analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo obtain in-depth insights without making steering groups feel monitored, we conducted qualitative semi-structured group interviews in a workshop format (37). We positioned participants as experts and ourselves as learners to emphasize the importance of their perspectives. To ensure comparability with existing literature, the interview guide was based on the CFIR (38, 39), widely used to categorize implementation determinant as barriers and facilitators. The framework comprises five domains (Innovation, Inner Setting, Outer Setting, Individual, and Process) with a total of 39 constructs as well as implementation outcomes (40). In consultation with the research team, we selected relevant constructs and excluded the Innovation Domain (as it pertains to the intervention itself) (41) and the Process Domain (as data collection occurred at the program’s onset). For the same reason, \u003cem\u003eimplementability\u0026nbsp;\u003c/em\u003ewas used when eliciting possible barriers and facilitators to the utilization of the PDSA cycle. Damschroder et al. define \u003cem\u003eimplementability\u0026nbsp;\u003c/em\u003eas “the likelihood the innovation will be put in place or delivered”, thus a forward-looking concept (40).\u0026nbsp;Interviewees were therefore asked to name barriers and facilitators that they think will impact the successful utilization of the PDSA cycle to HPA implementation in the future.\u0026nbsp;Given that prior experience with PDSA cycle-like processes may be an important determinant of successful implementation of future HPA (25), we also asked interviewees about the extent to which the implementation of HPA has already been approached using a structured process, similar to the PDSA cycle. The workshop format was set up to work both on-site as well as online, was conducted by two researchers (always KS with another person who took field notes) and all interviews were recorded. A detailed description of the workshop format is provided in Additional File 2.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor the management and data analysis procedure, the framework method with its seven steps was chosen as a suitable methodological guideline, aligning with Salvati et al.’s approach and our ontological and epistemological position (32). The framework methodis particularly suitable for the aims of comparing contextual factors across schools and identifying potential patterns, based on qualitative data gathered through interviews (32). Although iterative this method included the following steps:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e(1) Transcription \u0026amp; (2) Familiarization with the interviews\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAll interviews were transcribed verbatim in the same format, pseudonymized, and KS and MS familiarized themselves with the interviews and the field notes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e(3) Coding\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eFirst, a relatively unspecified version of the updated CFIR was used as a codebook to test-code three interviews by hand. During this process, the researchers (KS and MS) took notes about ambiguities in the coding, extended it through inductively derived categories, merged some categories and revised the codebook. In a second round, the adapted codebook was tested again with the same three interviews and further adaptations were made until all ambiguities in coding were removed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e(4) Developing a working analytical framework \u0026amp; (5) Applying the analytical framework\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe codebook, as well as the adaptation steps are documented in the Additional File 3.\u0026nbsp;For the final coding, the codebook and all transcripts were uploaded to MAXQDA 2020 (42), a software facilitating qualitative research. All transcripts were double-coded by two researchers (KS and MS) following the codebook, and valences were assigned whether a context factor was perceived as facilitator (positive), as barrier (negative) or as mixed (39, 31). All conflicts were resolved through discussion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e(6) Charting data into the framework matrix\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eSpreadsheets were created for each school with CFIR domains and constructs on the x-axis and all quotes imported from MAXQDA 2020 (42). Thereby, one construct could be represented by one or multiple quotes per interview. Valence ratings were assigned color codes and the cell with the quotation was colored accordingly: facilitators in blue, barriers in red and mixed factors in purple. If, for example, a quote was that \u003cem\u003ethe schoolyard offers a lot of space for the implementation of movement offers\u003c/em\u003e, this quote would be inserted into the \u003cem\u003eInner Setting/Space\u003c/em\u003e column and, as a facilitator, colored blue. A mixed rating, colored purple, could either come from two or more contrasting statements in one construct or one statement, which includes a contrast in itself (e.g. \u003cem\u003esome teachers are really motivated, others don’t care at all\u0026nbsp;\u003c/em\u003ein the \u003cem\u003eIndividual Domain/Teachers)\u003c/em\u003e. Next, all valence ratings per construct were aggregated into a final rating based on the following scheme:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eBlue only = blue = positive\u003c/li\u003e\n \u003cli\u003eBlue AND purple only (no red) = blue/purple = mixed positive\u003c/li\u003e\n \u003cli\u003eBlue AND red (AND purple) = purple = mixed\u003c/li\u003e\n \u003cli\u003ePurple only = purple = mixed\u003c/li\u003e\n \u003cli\u003eRed AND purple only (no blue) = red/purple = mixed negative\u003c/li\u003e\n \u003cli\u003eRed only = red = negative\u003c/li\u003e\n \u003cli\u003eGrey = neutral, not mentioned\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFor prior experience with a structured process such as the PDSA cycle, we initially expected the responses to be categorized similarly to the other factors. However, the responses turned out to be dichotomous, with schools reporting either having or lacking prior experience with the use of structured processes like PDSA cycles. Consequently, we used blue to indicate prior experience (present) and red to indicate no prior experience (absent). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis procedure was repeated for each school, generating individual spreadsheets with final valence ratings. Another spreadsheet with constructs on the x-axis and schools on the y-axis was then created, where all ratings were imported and merged into a Matrix Heat Map (MHM) for cross-school comparison.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e(7) Interpreting the data\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eBoth the in-depth insights from the interviews and the visualization in the MHM were evaluated and compared across schools by the principal researcher and DC in order to address the research aims.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eSample\u003c/h2\u003e\n \u003cp\u003eOf the sampled 16 schools, nine schools with a total of 20 representatives, agreed to participate in the study. Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e gives an overview of the characteristics of the participating schools.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cem\u003eSchool Characteristics\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eFederal State\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eUrban/Rural\u0026sup1;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocio-economic index\u0026sup2;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of Students\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterview format\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e# of Representatives \u0026amp; Roles\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBerlin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e422\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 Principal, School psychologist\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBavaria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e161\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOn-site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 Principal, Teacher\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBavaria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOn-site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 Teachers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBaden-W\u0026uuml;rttemberg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOn-site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 Principal, Teachers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSaxony-Anhalt\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e176\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 Teacher\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBrandenburg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e450\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 Principal, Parent, Teacher\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRhineland-Palatinate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 Principal, Teacher\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSaarland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e191\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOnline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 Teacher\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHesse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e380\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOn-site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 Teacher, Parents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003cstrong\u003eNote.\u0026nbsp;\u003c/strong\u003eSchools provided information on federal state and number of students upon registration for the program. \u0026sup1;Based on data by the Federal Institute on Building, Urban Affairs and Spatial Development, 2021. \u0026sup2;Based on data by the SINUS-Institute.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\n \u003ch2\u003eContextual Factors and Matrix Heat Mapping\u003c/h2\u003e\n \u003cp\u003eIn the interviews, 15 factors were mentioned across the Outer, Inner Setting, and Individual Domains plus prior experience with the PDSA cycle or a similar, structured process. The MHM (see Fig. 1) illustrates that some factors were universally perceived as barriers or facilitators while others varied. First, we report commonalities, the factors that have the same valence for all schools, followed by differing factors and finally, we elaborate on a potential pattern. Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e present exemplary quotes (Q1 \u0026ndash; Q59) to illustrate the valence coding and highlight factor interactions.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cem\u003eCommonalities Across Schools\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDomain\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFactor\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eValence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e#\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQuote\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndividuals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParent Engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eBarrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Parents are the danger, it\u0026apos;s not a nice thing the way they set the example for their children.\u0026quot;\u003c/em\u003e (School G: 28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eQ2\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So you definitely have to ask the parents, yes, you can, you can teach up to a certain point, but with the parent at home, as I said, just throwing the pizza in the oven and turning on the TV. [...] By then, everything we said at school is pass\u0026eacute;, to put it bluntly. [...] That\u0026apos;s a very high goal, where you always get them on board and say \u0026ldquo;Guys, we can only initiate things and you have to practically end them\u0026rdquo;.\u0026rdquo; (School F: 84)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrincipals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eQ3\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;And that\u0026apos;s why I\u0026apos;m so glad, that you [the principal] got this going. It\u0026apos;s really great. Not every school does this, some just continue floating in their own comfort zone.\u0026rdquo; (School F: 128)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eQ4\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eAs a school principal, I now also have the obligation to promote health (School B: 97)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSteering Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eQ5\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eI would perhaps see it as a strength that the first step has basically been taken, that the school is prepared to engage with this topic at all. That there are teachers and parents who support this topic, i.e. that they have really opened up to tackling it. I definitely see that as an encouragement, because it\u0026apos;s not as if someone came in from outside and said: \u0026ldquo;Well, you have to implement this now\u0026rdquo;. In a way, that was the intrinsic motivation on the part of the school. (School F: 98)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eQ6\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eI simply said that it would be a great fit and then asked around who else would like to take part and then one of my colleagues and the school management immediately agreed and then we said we\u0026apos;d just do it. (School I: 16)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInner Setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTension for Change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eQ8\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;And I think, in general, these 4 priorities of the program are very important for us, where I have to say that we also have to work on them and not always just on the curriculum.\u0026rdquo;\u003c/em\u003e (School E: 49)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eQ9\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;But I think that now that it\u0026apos;s all on the increase, [\u0026hellip;] I think more needs to be done in this area. I think we need to do more in this area.\u0026rdquo;\u003c/em\u003e (School C: 147)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCompatibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;And we haven\u0026apos;t had that at the school yet and we now have to draw up a protection concept and it [the health promotion intervention] fits in really well.\u0026rdquo;\u003c/em\u003e (School I: 25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMaterials \u0026amp; Equipment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, it has to be said that we are also well equipped technically.\u0026rdquo;\u003c/em\u003e (School F: 20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We also have a lot of play materials [...] and now we also have the program boxes\u0026rdquo;\u003c/em\u003e (School G: 44\u0026ndash;46)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCommunication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So it\u0026apos;s also really short distances and you don\u0026apos;t have to make an appointment with the boss to start a program, he just sits next to me and says yes. But I really think that makes things a lot easier.\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSo the communication here in the team is easy and that\u0026apos;s really great.\u0026rdquo; (School D: 165\u0026ndash;166)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;As far as evaluation is concerned, we are actually in a good position. We have our own school app and we use it to carry out regular evaluations.\u0026rdquo; (School A: 39)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMission Alignment \u0026amp; Culture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eQ15\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We have already won two awards [...]. And we now want to put the whole thing together into a complete package [...]. And that\u0026apos;s actually how we came to say that this is actually the right puzzle to complete the picture.\u0026rdquo; (\u003c/em\u003eSchool B: 9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003cstrong\u003eNote.\u003c/strong\u003e Exemplary quotes from the interviews.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eCommonalities across schools\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eParent engagement\u003c/em\u003e was reported as an important barrier by all schools. The school representatives felt like they cannot achieve as much when parents are not involved or even act counterproductively to the health promotion efforts (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e \u0026ndash; Q1). Bringing the parents on board was a metaphor frequently used, however doing so was challenging for all schools (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e \u0026ndash; Q2). Conversely, \u003cem\u003ePrincipal\u003c/em\u003e support and engagement from \u003cem\u003eSteering Group\u003c/em\u003e members were reported as facilitators across all schools (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e \u0026ndash; Q3-Q6). Further universal facilitators were \u003cem\u003eTension for Change\u003c/em\u003e and \u003cem\u003eCompatibility\u003c/em\u003e, as well as sufficient \u003cem\u003eMaterials \u0026amp; Equipment\u003c/em\u003e. \u003cem\u003eTension for Change\u003c/em\u003e was given at all schools, as they described different health needs as the drivers for participation (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e \u0026ndash; Q8, Q9). \u003cem\u003eCompatibility\u003c/em\u003e of program components with existing HPA already implemented at the school was also described as mostly a facilitator (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e - Q10) as well as having enough \u003cem\u003eMaterials \u0026amp; Equipment\u003c/em\u003e to implement HPA (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e \u0026ndash; Q11, Q12). Two additional Inner Setting factors were exclusively reported as facilitators, though only about half of the schools mentioned them. The first, \u003cem\u003eRelational Communications\u003c/em\u003e, refers to the extent to which communication structures within the school support the future implementation of HPA through utilizing the PDSA cycle, as illustrated in Q13 and Q14 in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. The second, \u003cem\u003eMission Alignment \u0026amp; Culture\u003c/em\u003e, reflects the alignment between PDSA cycle utilization for HPA implementation with the school\u0026rsquo;s mission and culture (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e \u0026ndash; Q15).\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eDifferences across schools\u003c/h2\u003e\n \u003cp\u003e\u003cem\u003eTeacher Engagement\u003c/em\u003e was perceived as mixed barrier and facilitator by most schools because some but not all teachers were reported to be supportive (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q17). However, some schools report having committed teachers only (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q18), while others struggle with stronger skepticism among their group of colleagues (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q16). Another rather strong barrier, reported by almost all schools, with one exception, seems to be \u003cem\u003eRelative Priority \u0026amp; Time\u003c/em\u003e. The schools mostly reported limited time next to the requirements from the curriculum as a barrier (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q19-Q21). However, one school emphasized that integrating HPA into the curriculum could mitigate this issue (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q22). \u003cem\u003eWork Infrastructure\u003c/em\u003e comprises statements regarding the structural organization, e.g. full-day school or not, and how that plays out as a facilitator or barrier, but also regarding the staff level. Some schools feel like not being a full-day school limits their opportunities for future implementation of HPA (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e - Q23). In turn, others report being a full-day school as a facilitator to incorporate HPA into daily routines (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e - Q26). Regarding staff levels, some schools reported having enough teachers (in relation to the number students), but too few other personnel to support structured HPA implementation at the schools, resulting in a mixed rating (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e - Q25). Others do have exactly this additional staff in the form of school psychologists or social workers, thus reporting staffing as a facilitator (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q27). Schools lacking both teachers and additional personnel cited this as a barrier (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q24). \u003cem\u003eSpace\u003c/em\u003e, referring to the physical infrastructure at the schools was mentioned as an important determinant by all schools, but the anticipated impact differed greatly, with some schools perceiving their physical infrastructure as a barrier (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q28, Q29) and others as a facilitator (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q30, Q31).\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cem\u003eDifferences Across Schools\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDomain\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFactor\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eValence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e#\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQuote\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndividuals\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTeacher Engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBarrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The colleagues\u0026apos; skepticism is a barrier.\u0026quot;\u003c/em\u003e (School E: 70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It always depends, so some colleagues really do a lot [...] and in other classes it\u0026apos;s less. Very different.\u0026rdquo; (\u003c/em\u003eSchool H: 16\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;And also the staff [is a facilitator] \u0026mdash;since we are all people who chose this school because of these factors [the school mission and health focus], everyone here is genuinely committed to it.\u0026quot; (\u003c/em\u003eSchool B: 90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInner Setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime \u0026amp; Relative Priority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBarrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;These programs are well designed but simply too much alongside regular school tasks.\u0026quot;\u003c/em\u003e (School D: 150)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The main thing that makes it really complicated is simply the time.\u0026quot;\u003c/em\u003e (School E: 97)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So you can expand the topic endlessly, yes. But you just have to see how far, what you do. Do you take something away from the lessons and that\u0026apos;s the thing.\u0026rdquo; (\u003c/em\u003eSchool F: 60\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Strictly speaking, you have to say that it\u0026apos;s all there in the curriculum and you just have to be clever and realize that it\u0026apos;s part of it.\u0026rdquo;\u003c/em\u003e (School B: 78)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWork Infrastructure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBarrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Since we are not a full-day school, they are picked up at 1 PM, which means we don\u0026apos;t have the option to say that we will extend activities. We really try to do this through support courses and other programs... However, much more could be done.\u0026quot;\u003c/em\u003e (School H: 31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The shortage of staff is really an issue right now, with the wave of illness and the lack of teachers [\u0026hellip;] and it\u0026rsquo;s not just affecting us but also other schools. (\u003c/em\u003eSchool B: 92\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMixed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Teachers pretty well, but as I said, [\u0026hellip;] everything that is important, you need additionally.\u0026rdquo; (\u003c/em\u003eSchool D: 179)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I mean, we are a full-day school, and that naturally brings a different perspective on the child, where you can see that we spend a long time together here. We are finding a way to structure the lessons so that it creates a health-promoting daily routine for everyone involved.\u0026quot; (\u003c/em\u003eSchool B: 13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;We have a new school psychologist starting today who will really provide support.\u0026quot; (\u003c/em\u003eSchool F: 36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpace\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eBarrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Space is a big issue, big space problem. Has been an issue for over 8 years\u0026rdquo; (\u003c/em\u003eSchool I: 65)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Well, that the school gym is not always available. [...] Yes, so the spatial conditions, that we really only ever have the classrooms or the schoolyard available and the gym is not always free\u0026rdquo; (\u003c/em\u003eSchool E: 72)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, how are you set up there (in terms of space)?\u0026rdquo; W: \u0026ldquo;Hey great, I think it\u0026apos;s great. [\u0026hellip;] It\u0026apos;s mega here.\u0026rdquo; (\u003c/em\u003eSchool D: 154\u0026ndash;158)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We are actually very well equipped in terms of space.\u0026rdquo;\u003c/em\u003e (School B: 21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOuter Setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLocal Conditions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBarrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The gyms are completely packed, it has to be said. This goes for other schools and clubs as well. Everything is full, which is nice, of course. But in the afternoons, for example, there are hardly any sports clubs because there\u0026rsquo;s no space. The people are available, but not the venue.\u0026quot; (\u003c/em\u003eSchool I: 84\u0026ndash;85)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The schoolyard is also rented by the city and the question is who does what [...] and it\u0026apos;s a traffic training area, so it\u0026apos;s also a parking lot for people who go to the sports hall, so it\u0026apos;s not separated.\u0026rdquo; KS: Ok, and they said they weren\u0026apos;t allowed to change that either. \u0026ldquo;Yes, so most of the schoolyard has to stay like this because of the traffic signs.\u0026rdquo; (\u003c/em\u003eSchool H: 48\u0026ndash;50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;We have fields and forests here\u0026mdash;really ideal conditions.\u0026quot; (\u003c/em\u003eSchool G: 30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePartnerships\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBarrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Even with the cafeteria, which opens during the 2nd break. They only sell crap.\u0026rdquo; (\u003c/em\u003eSchool I: 45\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;We have many after-school sports groups, and we also receive some support from associations, or we have partnerships with sports clubs.\u0026quot; (\u003c/em\u003eSchool F: 65)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Nutrition is such that we are in close contact with the food providers; we are definitely working to promote health and collaborate closely.\u0026quot; (\u003c/em\u003eSchool B: 53)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinancing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eBarrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Financial resources, that\u0026apos;s always somewhat of a problem (\u003c/em\u003eSchool I: 79\u003cem\u003e).\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eWe can, but then the question is who finances it (...). We wanted a multifunctional space like this upstairs, but it costs \u0026euro;20,000 and then it\u0026apos;s always rejected.\u0026rdquo; (\u003c/em\u003eSchool H: 50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So we can actually add financial resources [\u0026hellip;] that\u0026apos;s not the problem here. So there\u0026apos;s also something from the school board, from the side, so if I have a budget for next year, I can definitely take something from that.\u0026rdquo; (\u003c/em\u003eSchool B: 103)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003cstrong\u003eNote.\u003c/strong\u003e Exemplary quotes from the interviews.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003eClosely related, but part of the Outer Setting domain is the factor \u003cem\u003eLocal Conditions\u003c/em\u003e, which we consolidated with the factor \u003cem\u003ePolicies \u0026amp; Laws\u003c/em\u003e, as it was only mentioned by one school. For example, one school viewed having a nearby forest as a facilitator (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q34), whereas others cited limited outdoor space (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q32), or a schoolyard used as a public parking lot as barriers (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q33). The next category, \u003cem\u003ePartnerships \u0026amp; Connections\u003c/em\u003e, refers to collaborations with external organizations e.g. sports clubs. While most schools reported having supportive partnerships (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q36, Q37), some schools struggle with their partnerships, perceiving them as a barrier (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q35). The last category, \u003cem\u003eFinancing\u003c/em\u003e, was coded for any statements regarding financial resources as barriers or facilitators. Some schools perceived financing, or more often the lack of it, to be a fundamental barrier (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash; Q38, Q39), while others reported to have sufficient financial resources available (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e \u0026ndash;Q40).\u003c/p\u003e\n \u003cp\u003eThe responses to the question about prior experience with the PDSA cycle or a similar, structured process fell into two categories and are listed in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e (Q41-Q49). Either school representatives reported already working in a structured manner and having prior experience e.g. \u0026quot;We are, and the school leadership or the deputy principal is already very structured. And when we develop something, like a media concept, it runs very smoothly\u0026quot; (School C), or they reported working rather unstructured and lacking prior experience e.g. \u0026quot;I actually don\u0026rsquo;t see any structure in the processes yet\u0026quot; (School E). None of the schools indicated having fully utilized the PDSA cycle prior to the program.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003cdiv class=\"gridtable\"\u003e\u003cbr\u003e\n \u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cem\u003ePrior Experience with a Structured Approach\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSchool\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStructured Approach\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e#\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQuote\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;However, our overall approach to implementation is already very structured...I\u0026apos;ll put it this way, it\u0026apos;s constantly growing. It goes on and on.\u0026rdquo;\u003c/em\u003e (School A: 31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So it\u0026apos;s already very structured, institutionalized, where I\u0026apos;ve seen that if you just do it regularly, then it just becomes second nature.\u0026rdquo;\u003c/em\u003e (School B: 20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;We are, and the school leadership or the deputy principal is already very structured. And when we develop something, like a media concept, it runs very smoothly.\u0026quot;\u003c/em\u003e (School C: 173\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePresent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We\u0026apos;re actually already quite far along. We recognized things and then tried to land some projects. Also with people from outside. To implement them, to evaluate them. But of course, the harvest, we\u0026apos;re not quite there yet, it just takes time.\u0026rdquo;\u003c/em\u003e (School D: 124)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I actually don\u0026rsquo;t see any structure in the processes yet.\u0026quot;\u003c/em\u003e (School E: 53)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It is not yet anchored in any structure\u0026rdquo;\u003c/em\u003e (School F: 20) \u003cem\u003e\u0026ldquo;These are always just small, selective things that come up from time to time, exactly, but they don\u0026apos;t, as they say, keep repeating themselves in a rotating loop.\u0026rdquo;\u003c/em\u003e (School F: 49)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I just think it\u0026apos;s all a bit piecemeal, not structured\u0026rdquo;\u003c/em\u003e (School G: 21) \u003cem\u003e\u0026ldquo;What we lack is evaluation. There\u0026apos;s nothing there yet, because the other things are also a bit behind.\u0026rdquo;\u003c/em\u003e (School G: 32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eH\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eWe do a lot, but not with such a background and structured approach.\u003c/em\u003e (School H: 4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAbsent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eAgain, there are so many individual aspects that count, but still no single common thread, no structure.\u003c/em\u003e (School I: 55)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003cstrong\u003eNote.\u003c/strong\u003e Quotes from the interviews.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\n \u003ch2\u003ePotential pattern\u003c/h2\u003e\n \u003cp\u003eThrough the visualization of the contextual factors a potential pattern of interaction emerged that could not be directly traced back to any of the sampling factors. Instead, schools with a higher relative amount of anticipated contextual barriers versus anticipated contextual facilitators reported no prior experience with structured approaches such as PDSA cycles. We therefore believe this pattern is an indicator of implementability. Schools, which reported to have some structure in their HPA reported most of their contextual factors as facilitators. The opposite seemed to be true for schools, which are not yet structured in their HPA. All schools with prior experience using a structured approach (Schools A-D) reported at least some positive \u003cem\u003eRelational Communications\u003c/em\u003e, while none of the schools without prior experience (Schools E-I) did so. Further, none of the four schools with prior experience reported \u003cem\u003eFinancing\u003c/em\u003e to be a barrier, but rather three of these reported it to be a facilitator and the other one reported financing as neutral or not salient. Finally, space was perceived as more of a barrier than facilitator by four of the five schools without prior experience, but none of those with prior experience.\u003c/p\u003e\n \u003cp\u003eSome schools also reported that some contextual factors influenced others, acting as reinforcing barriers or facilitators. However, these interactions were not consistent across schools but may serve as a starting point for further exploration. One such factor was \u003cem\u003eFinancing\u003c/em\u003e. A lack thereof was mentioned as influencing \u003cem\u003ePartnerships \u0026amp; Connections\u003c/em\u003e, the available \u003cem\u003eSpace\u003c/em\u003e and \u003cem\u003eWork Infrastructure\u003c/em\u003e (School I, F, D; Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e \u0026ndash; Q50-52). In turn, low staff levels \u003cem\u003e(\u003c/em\u003eas part of \u003cem\u003eWork Infrastructure)\u003c/em\u003e in combination with low \u003cem\u003eRelative Priority \u0026amp; Time\u003c/em\u003e was mentioned to influence \u003cem\u003eRelational Communications\u003c/em\u003e and ultimately \u003cem\u003eParent Engagement\u003c/em\u003e (School I; Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e \u0026ndash; Q53). Additionally, positive reinforcements were reported in some schools. For example, having a strong \u003cem\u003eMission Alignment\u003c/em\u003e and a health-promoting \u003cem\u003eCulture\u003c/em\u003e was perceived as positively influencing future \u003cem\u003eTeacher\u003c/em\u003e and even \u003cem\u003eParent Engagement\u003c/em\u003e in one school (School B, C; Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e \u0026ndash; Q54-Q56). Further, \u003cem\u003eRelational Communications\u003c/em\u003e, in the form of established communication structures, were perceived as positively influencing both \u003cem\u003eTeacher\u003c/em\u003e and again \u003cem\u003eParent Engagement\u003c/em\u003e, as well as a conducive \u003cem\u003eWork Infrastructure\u003c/em\u003e (School A; Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e \u0026ndash; Q57-Q59).\u003c/p\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cem\u003eInteractions of Factors\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDomain\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFactor\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eValence\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e#\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eQuote\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOuter Setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinancing \u0026amp; Local Conditions\u003c/p\u003e\n \u003cp\u003e\u0026loz; Partnerships \u0026amp; Connections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBarrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Our caterer is a disaster, a real disaster. That would be great, of course, but it\u0026apos;s not going to happen, you can\u0026apos;t get rid of them. [...] Yes, and because there aren\u0026apos;t any around here who do that. And it\u0026apos;s also a cost factor.\u003c/em\u003e (School I: 31\u0026ndash;33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOuter Setting \u0026ndash; Inner Setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinancing \u0026loz; Space\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBarrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The problem at the moment is that we don\u0026apos;t have a school kitchen. But we\u0026apos;re doing a charity run soon, where we want to raise money for it. Because we can only tackle the issue of nutrition if we have a functioning school kitchen where we can try things out.\u0026rdquo;\u003c/em\u003e (School F: 49)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOuter Setting \u0026ndash; Inner Setting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFinancing \u0026loz; Work Infrastructure (Staff Level)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBarrier\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So if we have to get finances from external sources, then it becomes difficult, so as soon as it\u0026apos;s somehow done through the school, then it\u0026apos;s not a problem, but as soon as it\u0026apos;s something bigger and people have to be hired, we reach our limits.\u0026rdquo;\u003c/em\u003e (School D: 175)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInner Setting \u0026ndash; Individuals Domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eStaff Level, Time \u0026loz; Relational Communications \u0026loz; Parent Engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBarriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Parents should be brought on board much more. I think this is neglected due to lack of patience, lack of time and the many sick leaves. More conversations should be held if capacity allows.\u0026rdquo;\u003c/em\u003e (School I: 80\u0026ndash;83\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eInner Setting \u0026ndash; Individuals Domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eMission Alignment/Culture \u0026loz; Teacher Engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;And also the staff, because we are all people who chose this school because of the factors, and they are all people here who want it too.\u0026rdquo;\u003c/em\u003e (School B: 90)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;So there will be colleagues who say they don\u0026apos;t feel like it [...] But I would say that 80% of colleagues would already be open to it. We are also a committed school here.\u0026rdquo;\u003c/em\u003e (School C: 317)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInner Setting \u0026ndash; Individuals Domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMission Alignment/Culture \u0026loz; Parent Engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The fact that they chose this school because of the concept is, of course, another driving force, [...] of course, we want it out of our own conviction, but the parents are also behind it and want to support it.\u0026rdquo;\u003c/em\u003e (School B: 15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eInner Setting \u0026ndash; Individuals Domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eRelational Communications \u0026loz; Teacher and Parent Engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Communication was transparent, it was also announced and presented to the entire school management. Also in the committee: that is the school management, certain teachers, educational specialists, secretaries. And they then take the information back to their areas. Since the program is also suitable for substitute teaching, the program was then briefly presented to the entire teaching staff at the general conference.\u0026rdquo;\u003c/em\u003e (School A: 12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Otherwise it would be nice if there was more parental involvement and more interest. Among parents and teachers. But we are confident about that too. We have laid the groundwork, we have communicated it [...]\u0026rdquo;\u003c/em\u003e (School A: 14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eInner Setting \u0026ndash; Individuals Domain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRelational Communications \u0026loz; Work Infrastructure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFacilitator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQ59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We have established communication structures where we exchange information. I wanted to get away from the questionnaires, evaluating, extra work. This is how it fits into the teaching context, the daily work routine. We now have weekly situations where we exchange ideas and get feedback.\u003c/em\u003e (School A: 40\u0026ndash;41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003cstrong\u003eNote.\u003c/strong\u003e Exemplary quotes from the interviews.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/div\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis paper aimed to identify contextual factors that are perceived to facilitate or inhibit the future utilization of the PDSA cycle for implementing HPA, uncover differences across German primary schools, and explore how these factors interact and potentially form patterns. Taking a systems thinking perspective, we also examine these findings in relation to the debate on context-specificity versus generalizability in implementation research (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe identified an overarching pattern whereby schools with prior experience in a structured process similar to the PDSA cycle reported more contextual facilitators, whereas those without prior experience reported more barriers. Prior experience with a structured process similar to the PDSA cycle has been shown to impact its implementation for future school improvement (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Our findings build on and extend this by highlighting the potential role that prior experience may have in reducing perceived contextual barriers and increasing facilitators for the future utilization of the PDSA cycle for HPA implementation. We found prior experience to be associated with strong communication structures and sufficient financial support as facilitators, whereas the absence of prior experience was linked to financial constraints as a barrier and a lack of mention of communication structures as a facilitator.\u003c/p\u003e \u003cp\u003eThis raises the question of causality: Does utilizing a PDSA-cycle-like structured approach help overcome barriers, or are schools with fewer barriers and more facilitators better prepared for utilizing the PDSA cycle? Due to the cross-sectional nature of this study, we cannot establish any causal direction. However, it is worth considering whether teaching the PDSA cycle alone is sufficient to overcome barriers to its application, or if additional strategies are needed to facilitate structured HPA implementation.\u003c/p\u003e \u003cp\u003eFrom a systems thinking perspective, interactions shape the system\u0026rsquo;s behavior (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). If, as in the present case, utilizing the PDSA cycle for HPA implementation is the desired behavior of the system, having well-functioning and supportive communication structures might be an important prerequisite. Teaching school personnel, particularly leadership, how to establish such communication structures might be a capacity-building strategy needed to facilitate the use of PDSA cycles for HPA implementation.\u003c/p\u003e \u003cp\u003eFurther, effective communication, cooperation, and organization might also help bring important stakeholders on board (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Engaging stakeholders may be particularly relevant, as in Germany, the amount of budget schools receive depends on the school authorities (mainly community and partly federal state) (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). However, other stakeholders such as parent initiatives, sports clubs, and health insurance companies could provide additional funds and resources to be used for HPA in particular (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Helping schools communicate their intention to become a HPS to these stakeholders could facilitate the acquisition of additional financial resources.\u003c/p\u003e \u003cp\u003eBased on our case-based insights, financial resources may also impact other factors, such as space, partnerships, and work infrastructure. From a systems thinking perspective, supporting schools in acquiring more resources from stakeholders could initiate a cascade of positively reinforcing loops, gradually removing further barriers (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Future research should investigate and model these potential interactions and feedback loops using methods such as causal loop diagramming (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOn a practical level, for schools to be able to communicate their mission to stakeholders and get them on board, there must first be clarity about the mission. In most theories on organizational change commonly used in school improvement, a clear mission plays a key role in guiding change and development (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), which was also mentioned in some cases in our data. Further, having a clear mission can guide not only the school team through the process of change but could also help get the parents on board if communicated and embodied well (\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). This additionally suggests that it might be worthwhile to support schools in developing a health-centered school mission, ensuring strong commitment to it, and aligning structures and work processes accordingly, alongside teaching communication skills to build capacity.\u003c/p\u003e \u003cp\u003eAnother perspective to consider is that the PDSA cycle could technically be used for addressing all the above mentioned factors, setting up better communication structures, a mission statement and a strategy for stakeholder engagement (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Thus, more research is needed to investigate how these factors interact and stand in causal relationships with each other in a larger sample of schools to be able identify and target the root causes more effectively. One method suitable for such an investigation is Coincidence Analysis (CNA), as it identifies configurations of factors leading to a specific outcome (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). As a preselection of factors is necessary for this method, our study has made an important contribution to such a research endeavor by narrowing down possible difference makers to use in CNA (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIndependent of prior experience, and thus presumably generally valid for German elementary school, were the barriers lack of \u003cem\u003eParent Engagement\u003c/em\u003e, \u003cem\u003eWork Infrastructure\u003c/em\u003e, comprised of staff levels and school organization, and \u003cem\u003eRelative Priority \u0026amp; Time\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eAll schools highlighted to some degree that without \u003cem\u003eParent Engagement\u003c/em\u003e, they feel limited in their agency. This finding aligns with our systems thinking perspective, viewing schools as complex adaptive systems that require meaningful interactions with stakeholders, particularly parents, to achieve successful and sustainable health promotion (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). As mentioned above, a lived mission statement as well as strong communication structures might improve parent engagement according to literature (\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). However, we saw this only in one school, resulting in a mixed rather than a negative rating of parent engagement. This indicates a special need to understand why parents do not engage and identify additional strategies to overcome this barrier, and it is possible that PDSA cycles will be insufficient in doing so.\u003c/p\u003e \u003cp\u003eRegarding the \u003cem\u003eWork Infrastructure\u003c/em\u003e construct, being organized as a full-day school naturally provides more time for HPA. Further, transitioning to a full-day school also requires capacity for implementing several profound changes on an organizational level, and as by 2026, all primary schools are technically obligated to provide full-day care, there might be synergies in change processes worth leveraging (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Additionally, low staff levels are a systemic problem as Germany is facing a significant teacher shortage, exacerbated by high mental health burdens among educators (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Improving teacher mental health through targeted interventions could thus be seen as another capacity-building strategy and a prerequisite for the successful application of the PDSA cycle for HPA implementation.\u003c/p\u003e \u003cp\u003eLastly, aligning with Scheffler et al., our results indicate that while schools intend to utilize the PDSA cycle to implement HPA, they often perceive this as unattainable due to the high demands and multiple requirements of the curriculum (\u003cem\u003eRelative Priority \u0026amp; Time\u003c/em\u003e) (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Framke \u0026amp; Sorensen suggested that, to achieve organizational change, the primary task of the organization should be at the center of each change initiative (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). The primary task of German elementary schools is \u0026ldquo;to enable basic school education in a joint educational programme for all children [with] the goal [\u0026hellip;] to acquire and extend basic and adaptable competences\u0026rdquo; (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Program designers could focus on highlighting how the PDSA cycle can be used not only for the implementation of HPA but also for other school improvement processes that might be perceived as closer to the primary task and for integrating HPA within curricula-based activities.\u003c/p\u003e \u003cp\u003eOverall, we aimed to contribute to the debate on context-specificity versus generalizability in implementation research. Randomly addressing contextual determinants across all sites, schools in our case, risks inefficient resource allocation while individual context assessments and tailored strategies would be equally resource-intensive and impractical (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Our pattern-based approach offers a potential solution by focusing on the a priori identification of a set of key factors, allowing for more targeted strategy selection. This could help balance the need for context-specific tailoring with the benefits of generalizable strategies such as the PDSA cycle (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). A similar methodological approach has been used once prior to our work and has proved its benefits for implementation evaluation in the clinical setting (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). We can thus conclude that the approach is valuable in offering a way forward in regard of the context-specificity versus generalizability debate for more than one topical implementation field.\u003c/p\u003e \u003cp\u003eThis study has several strengths and limitations that should be considered. A strength is the innovative method combination and the systems thinking perspective which enabled us to understand the complexity of the matter and generate novel insights on key contextual factors, potential interactions and a pattern. However, this exploratory approach necessitates future research to generate more robust findings, as the sampling strategy and resulting small sample size may limit the generalizability of the results. Additionally, all participating schools had already decided to implement the program, which may have led to a neglect of barriers regarding the initial adoption decision. Furthermore, discussing leadership and steering group motivation and support in the presence of their members may have influenced responses due to social desirability bias. From a methodological perspective, the MHM visualization used to compare contextual factors across schools does not capture all nuances of the qualitative data, and the very open and explorative nature of the study led to gaps in the data, leaving some aspects underexplored. More targeted follow-up questions to schools could have provided deeper insights into the identified barriers and facilitators.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur findings suggest that contextual factors shape the perceived implementability of PDSA cycles for HPA in schools. Schools with prior experience in structured change processes reported fewer anticipated barriers and more facilitators, indicating a potential link between applying structured implementation approaches and reductions in perceived challenges. However, it remains unclear whether prior experience actively reduces barriers or if schools with fewer barriers are simply better positioned to adopt structured processes. A key finding of this study is the potential role of communication structures in supporting the successful use of the PDSA cycle. Strengthening internal and stakeholder communication may assist schools without prior experience in adopting structured capacity-building strategies and potentially help mitigate other barriers for utilization such as a lack of financial support. Additionally, some barriers\u0026mdash;such as lack of parent engagement, time, and work infrastructure\u0026mdash;were reported across all schools, regardless of prior experience. Whether the full application of the PDSA cycle can help overcome these universal barriers or other, more specific strategies are needed remains unclear.\u003c/p\u003e \u003cp\u003eBy adopting a systems thinking perspective and applying a matrix heat mapping approach to qualitative data, our study offers a structured way to explore implementation complexity within and across school settings. This approach enabled the identification of both shared and unique contextual factors, and helped uncover a potential pattern of determinant factors linked to prior experience. As such, our method contributes to the broader debate on context-specificity versus generalizability in implementation research. It may offer a pragmatic path forward in other complex implementation settings as well.\u003c/p\u003e \u003cp\u003eFuture research should test this approach in larger, more diverse samples and examine causal relationships between contextual factors, PDSA cycle utilization, and capacity development. This may help balance tailored and generalizable strategies in school health promotion and beyond.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCFIR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConsolidated Framework for Implementation Research\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMHM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMatrix Heat Map\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHPA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHealth-promoting activities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHPS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHealth Promoting School\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePDSA cycle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePlan-Do-Study-Act cycle\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThe ethics committee of the Technical University of Munich approved of the study prior to any data collection procedures in September 2023 (\u003cem\u003e2023-12-NM-KH\u003c/em\u003e). Consent was obtained from all participants prior to conducting the interviews.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe project is funded by the health insurance company DAK Gesundheit and the planero GmbH. The funders did not have a role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\u003ch2\u003eAuthors' contributions\u003c/h2\u003e \u003cp\u003eKS was mainly in charge of the study and the writing of this manuscript. SB mainly contributed to the conceptualization of the study. Interviews were conducted by KS, supported by SB and student assistants. The codebook was developed and the interviews were coded by KS and MS. DC supported KS majorly in the creation of the MHM, the interpretation of the results and the discussion. KS wrote the manuscript with conceptual support from FM, SB and FB. SB, FM and DC commented the writing. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eWe express our gratitude to all school representatives for their participation. We thank our research assistants Anna Kaufmann, Philippa Winter, and Laura Eipel for their assistance in interviewing and transcribing.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eThe pseudonymized interview data used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWHO. Ottawa Charter for Health Promotion. 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Gelingens- und Hindernisfaktoren bei der Implementierung von Gesundheitsf\u0026ouml;rderung in Kitas und Grundschulen anhand von 4 ausgew\u0026auml;hlten Projekten. Bundesgesundheitsbl. 2024;67(9):1021\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFramke E, S\u0026oslash;rensen OH. Implementation of a participatory organisational-level occupational health intervention - focusing on the primary task. IJHFE. 2015;3(3/4):254.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavis M, Beidas RS. Refining contextual inquiry to maximize generalizability and accelerate the implementation process. Implement Res Pract. 2021;2:2633489521994941.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"School Health Promotion, Capacity-Building, PDSA cycle, Implementation, Context, Generalizability, Matrix Heat Map, Data Visualization, Systems Thinking","lastPublishedDoi":"10.21203/rs.3.rs-6079185/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6079185/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBecoming a health-promoting school requires capacity to implement ongoing health promotion activities (HPA). Enhancing schools\u0026rsquo; ability to manage change processes\u0026mdash;e.g. through a plan-do-study-act (PDSA) cycle\u0026mdash;has been identified as a promising capacity-building approach. However, contextual conditions at individual schools may influence the utilization of the PDSA cycle for HPA implementation. Understanding this influence is critical to determine whether tailored approaches are needed or whether the PDSA cycle can serve as a generalizable, effective strategy. This study aimed to investigate whether, which, and how contextual factors determine the application of the PDSA cycle for HPA implementation and to reflect on the methodological approach\u0026rsquo;s value for implementation research.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study was part of an evaluation of a large-scale school health promotion program designed to build capacity through teaching the PDSA cycle. We combined qualitative interviews with representatives from nine schools with matrix heat mapping to visualize contextual factors influencing the perceived implementability of HPA using the PDSA cycle. Schools were compared to identify commonalities, differences, and determinant patterns.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSchool representatives reported various contextual factors potentially influencing PDSA cycle utilization for future HPA implementation. Schools with prior experience using structured, PDSA-cycle-like processes perceived fewer contextual barriers and more facilitators, suggesting either the effectiveness of a structured approach or the necessity of certain contextual facilitators. Supportive communication structures, sufficient financial means, and space emerged as potential consequences of using structured processes or prerequisites for PDSA cycle use. Although lack of parental engagement, work infrastructure barriers, and time constraints were reported across nearly all schools, they did not inhibit some from applying structured processes.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eContextual factors shape the implementability of the PDSA cycle for HPA in schools. Whether these factors are prerequisites or can be shifted through applying the PDSA cycle remains unclear. Our study offers a methodological approach to examine implementation context in complex, multi-site settings. This approach may help identify determinant patterns and inform the broader debate on generalizability versus context-specificity in implementation research. Future studies should test this approach in larger, more diverse samples to guide strategy selection and inform scaling efforts.\u003c/p\u003e","manuscriptTitle":"Visualizing potential contextual influences in and across complex settings: a qualitative study on structured school health promotion implementation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-12 10:42:44","doi":"10.21203/rs.3.rs-6079185/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-07-08T08:47:23+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-07T10:09:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-02T07:03:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"Implementation Science Communications","date":"2025-04-01T04:03:06+00:00","index":"","fulltext":""},{"type":"decision","content":"Major revision","date":"2025-03-03T06:07:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7b7ca10c-7563-419f-80a0-23382edb0f95","owner":[],"postedDate":"May 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-19T17:22:54+00:00","versionOfRecord":{"articleIdentity":"rs-6079185","link":"https://doi.org/10.1186/s43058-026-00861-x","journal":{"identity":"implementation-science-communications","isVorOnly":false,"title":"Implementation Science Communications"},"publishedOn":"2026-01-16 16:29:50","publishedOnDateReadable":"January 16th, 2026"},"versionCreatedAt":"2025-05-12 10:42:44","video":"","vorDoi":"10.1186/s43058-026-00861-x","vorDoiUrl":"https://doi.org/10.1186/s43058-026-00861-x","workflowStages":[]},"version":"v1","identity":"rs-6079185","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6079185","identity":"rs-6079185","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}