Validity of the Japanese version of health promoting school implementation questionnaire

Validity of the Japanese version of health promoting school implementation questionnaire | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Validity of the Japanese version of health promoting school implementation questionnaire Akira Kyan, Kiyonori Masukawa, Minoru Takakura This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7945462/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Apr, 2026 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract Background Despite the global spread of the Health-Promoting School (HPS) framework, few validated instruments assess the depth and quality of its implementation, particularly in non-Western contexts. The Health-Promoting School Implementation Questionnaire (HPSIQ), developed in the Netherlands, has demonstrated sound psychometric properties but has not been validated in Asia. Objectives This study tested the factor structure and concurrent validity of the Japanese version of the HPS Implementation Questionnaire (J-HPSIQ) in relation to school health directors’ (SHDs’) health literacy on social determinants of health (SDH-HL). Methods A web-based survey was conducted among 1,295 staff from 174 public high and special needs schools in Japan (2023). The seven-factor structure of the 28-item J-HPSIQ—Adherence, Dose, Participant Responsiveness, Quality of Delivery, Integration, Program Differentiation, and Adaptation—was tested using confirmatory factor analysis (CFA). Convergent and discriminant validity were examined through composite reliability (CR), average variance extracted (AVE), the Fornell–Larcker criterion, and heterotrait–monotrait (HTMT) ratios. To assess concurrent validity, multiple linear regressions examined associations between SHDs’ SDH-HL and school-level implementation scores, adjusting for demographic and school-level covariates. Results The initial CFA showed moderate-to-fair fit. A subsequent structural model specified Adherence as a dependent construct predicted by Dose, Participant Responsiveness, Quality of Delivery, and Integration. This model improved fit (χ ² (604) = 1069.62, CFI = 0.840, TLI = 0.820, RMSEA = 0.083; Δχ²(15) = 211.0, p 0.80 and AVE ≥ 0.36. SHDs’ SDH-HL was positively associated with total implementation (β = 0.21, p < 0.01), especially with Quality of Delivery (β = 0.47, p < 0.001), Integration (β = 0.23, p < 0.01), and Adaptation (β = 0.29, p < 0.01). Conclusions The J-HPSIQ is a psychometrically robust and contextually relevant tool for evaluating school health promotion in Japan. SHDs’ health literacy was positively related to effective and adaptive HPS implementation, highlighting the importance of organizational literacy for equitable and sustainable school health systems. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research School health promotion Implementation fidelity Health literacy Psychometric validation Japan Introduction School-based health promotion has increasingly been recognized as a cornerstone of population health and health equity. The World Health Organization’s (WHO) Health-Promoting School (HPS) framework represents a paradigmatic shift from individual health education toward a whole-school approach that embeds health within the educational mission, organizational structures, and everyday ethos of schools ( Making every school a health-promoting school – Global standards and indicators , 2021; World Health Organization and the UNESCO, 2021 ). This framework reconceptualizes the school as a key setting for shaping lifelong health behaviors and fostering social inclusion. It rests on six interdependent pillars: (1) comprehensive health education, (2) a safe and supportive environment, (3) access to school health services, (4) family and community partnerships, (5) the development of coherent health policies, and (6) organizational capacity for health promotion (Wourld Health Organization, 2000 ). A growing body of meta-analytic evidence demonstrates that the HPS approach improves diverse adolescent outcomes—including diet, physical activity, substance use, and mental well-being—across varied sociocultural contexts (Goldberg et al., 2019 ; Langford et al., 2015 ; Lekamge et al., 2025 ). Accordingly, the HPS framework has evolved into a global reference model for equity-oriented, school-based health promotion. Despite this evidence base, systematic tools for assessing the depth and quality of HPS implementation within schools remain limited. As noted by Kazemitabar et al., only 7 of 649 HPS-related studies examined psychometric properties, revealing a striking absence of validated metrics capable of capturing organizational and cultural dimensions of implementation (Kazemitabar et al., 2020 ). To fill this gap, Vennegoor et al. developed the Health-Promoting School Implementation Questionnaire (HPSIQ) —a theoretically grounded, 28-item instrument designed to appraise school-level enactment of HPS principles across domains such as policy, environment, pedagogy, community partnerships, and evaluation (Vennegoor et al., 2023 ). The HPSIQ demonstrated sound factorial validity and strong internal consistency (Cronbach’s α = .71–.91), and has since been adopted across Europe as a diagnostic tool for guiding system-wide health promotion and educational reform. Nevertheless, the cross-cultural transferability of the HPSIQ has not been rigorously tested. Implementation of HPS principles is mediated by national education systems, professional norms, and institutional logics, and therefore requires validation within diverse governance and cultural frameworks. Japan, with its highly institutionalized school health system, provides a particularly instructive case. Japan’s school health system is anchored in a dense legal and administrative architecture that integrates health legislation, specialized personnel, national curricula, and formal coordination mechanisms (Tomokawa et al., 2020 ). Its statutory foundations—the School Education Act and the School Health and Safety Act —mandate periodic health examinations, infection control, environmental hygiene management, and health instruction. These policies guarantee a national minimum standard for school health practice. Within this framework, the Ministry of Education, Culture, Sports, Science and Technology (MEXT) defines three operational domains: health education, health management, and health organizational activities (Tomokawa, Shirakawa, et al., 2021). Health education cultivates students’ knowledge and behaviors through the health and physical education curriculum and guidance from licensed school nurse teachers ( yogo teachers). Health management encompasses daily monitoring, medical examinations, and infection control led by yogo teachers in collaboration with classroom teachers and parents. Health organizational activities include school health planning, teacher training, and intersectoral coordination managed by the school health director ( hoken shuji, SHD ). A distinctive institutional feature is the statutory involvement of the three school health professionals—school physicians, dentists, and pharmacists ( “gakkō sanshi” ). These professionals provide expertise in medical oversight, environmental hygiene, and health education, and their participation in school health committees institutionalizes collaboration between schools and external health systems (Tomokawa, Miyake, et al., 2021). This tripartite system is remarkably rare in global practice, reflecting Japan’s historically hybrid model of education and public health governance. While Japan’s system aligns structurally with HPS principles, empirical evidence regarding its functional alignment —that is, the extent to which schools operationalize these mandates as a holistic HPS approach—remains limited (Japan School Health Association, 2020 ). Formal compliance (e.g., mandated committees, policy documents) may not necessarily translate into substantive integration of health promotion within curricula, professional practice, or community partnerships. This implementation gap underscores the need for validated, context-sensitive instruments capable of mapping how institutional structures are enacted as lived practices within schools. To address both the need for cross-cultural validation of the Health-Promoting School Implementation Questionnaire (HPSIQ) and the need for a contextually grounded instrument to assess the implementation of school health activities in Japan, this study examined the psychometric validity of the Japanese version (J-HPSIQ). Specifically, we (1) tested its factorial structure using confirmatory factor analysis and (2) assessed its concurrent validity in relation to SHDs’ health literacy on social determinants of health (SDH-HL). In this study, SDH-HL was conceptualized as the concurrent construct, extending the notion of health literacy to the structural and societal domains. It encompasses the capacity to recognize, critically appraise, and act upon the social, economic, and environmental conditions that shape health inequities(Matsumoto & Nakayama, 2017 ). By emphasizing critical awareness of systemic determinants and the ability to translate such understanding into equity-oriented action, SDH-HL provides a framework for understanding how educators and administrators engage with and respond to the broader determinants of health within institutional settings. More broadly, health literacy (HL) has been recognized as a foundational determinant of health behavior, empowerment, and equity across public-health and educational systems. The integrated model proposed by Sørensen et al. defines HL as the ability to access, understand, appraise, and apply health information to make informed decisions regarding health promotion, disease prevention, and care (Sørensen et al., 2012 ). Importantly, HL is not viewed as a fixed cognitive ability but as a context-embedded social practice, shaped by cultural, institutional, and environmental conditions that influence how individuals and organizations interact with health information. Within schools, HL—and particularly SDH-HL—serves as the cognitive, ethical, and organizational foundation for implementing the Health-Promoting School (HPS) framework, which integrates inclusive education, supportive environments, and intersectoral collaboration. Empirical evidence supports this linkage: Dadaczynski et al. demonstrated that limited HL among school leaders was associated with lower levels of HPS implementation, even after adjusting for attitudes, competencies, and demographic factors (Dadaczynski et al., 2020 ) Together, these insights indicate that HL functions not only as an individual capability but also as an organizational capacity that enables the integration of health promotion into school governance and practice. Accordingly, examining the relationship between SHDs’ SDH-HL and the degree of HPS implementation provides a theoretically grounded test of the concurrent validity of the J-HPSIQ and advances understanding of how equity-oriented health literacy operates as a structural driver of health-promoting education systems. Methods Participants The target population comprised all 175 prefectural schools (148 general, vocational, or university-affiliated high schools; 27 special needs schools) in a large prefecture of western Japan encompassing both urbanized coastal areas and rural mountainous regions (population approximately 5.4 million). Because the Japanese school system is nationally standardized by the Ministry of Education, Culture, Sports, Science and Technology (MEXT)—with uniform curricula, staffing structures, and school health regulations—the participating schools can be regarded as broadly representative of the organizational context of Japanese secondary education. One school was excluded because a member of the research team (KM) was employed there, leaving 174 schools eligible. Recruitment targeted staff with primary responsibility for school health activities, including principals, heads of the health division SHDs, school management committee members (mainly section heads), yogo teachers, and health and physical education teachers. Because organizational structures vary and faculty may hold multiple roles, the exact denominator was indeterminate. A total of 1,295 staff members provided complete data and were included in the analysis (principals, n = 144; school management committee members, n = 779; SHDs, n = 114; health and physical education teachers, n = 161; yogo teachers, n = 97). Unlike our previous validation focused solely on high schools, the present HPSIQ validation included both high schools and special needs schools to reflect the heterogeneity of school health service delivery in Japan. Procedure Prior to data collection, the study protocol was presented to and approved by the Board of the Prefectural School Principals Association. Survey invitations and study information were emailed to each principal. Data were collected between November and December 2023 using an anonymous, self-administered web-based questionnaire (≈ 20 minutes). Up to three email reminders were sent before the response deadline. Electronic written informed consent was obtained from all participants prior to participation (participants indicated consent by selecting an “I agree” checkbox before accessing the questionnaire), with assurances of anonymity. All participants were adult school staff; therefore, consent from legal guardians was not required. All methods were performed in accordance with the Declaration of Helsinki and with the Ethical Guidelines for Medical and Biological Research Involving Human Subjects in Japan (MEXT/MHLW/METI), and were approved by the Ethics Committee of the Graduate School of Human Development and Environment, Kobe University (approval No. 685-3; revision-685-3). Measures Development of the Japanese Health-Promoting School Implementation Questionnaire (J-HPSIQ) The J-HPSIQ was developed to assess the degree of school-level implementation of the Health-Promoting School (HPS) framework in Japan. Adaptation from the Dutch Healthy School Questionnaire (Vennegoor et al., 2023 ) followed a forward–backward translation procedure. Two experts in school health/public health (AK, KM) reviewed content validity and cultural relevance, and a pilot test with school management committee members, health and physical education teachers, and yogo teachers confirmed clarity. The final J-HPSIQ comprised 28 items across seven domains: Adherence, Dose, Participant Responsiveness, Quality of Delivery, Integration, Program Differentiation (PD), and Adaptation. Items were scored on a 0–4 Likert scale (0 = not at all to 4 = to a very great extent); higher scores indicate greater implementation. Subscale and total scores were calculated as the mean of available items. Health Literacy on Social Determinants of Health (SDH-HL) The explanatory variable was staff health literacy regarding social determinants of health, measured using the Health Literacy on Social Determinants of Health Questionnaire (HL-SDHQ) (33 items; domains: access, understanding, appraisal, application)(Matsumoto & Nakayama, 2017 ). Example items include “Finding people who are socially isolated and in poor health,” “Understanding that people with lower income are more likely to become ill,” and “Judging what kinds of social inequalities exist in leading a healthy life.” Response options were “very easy,” “fairly easy,” “fairly difficult,” “very difficult,” “don’t know/not applicable.” Scoring followed prior work: 4, 3, 2, 1 points for the four ordered responses; “don’t know/not applicable” was replaced with the item mean among all respondents (Matsumoto & Nakayama, 2017 ). All participating staff completed the HL-SDHQ; no missing data were observed. For each school, item-level means were averaged across staff and then summed over 33 items to yield a school-level total score (range 33–132); higher scores reflect greater SDH-related health literacy. Covariates Demographic and occupational characteristics were used as covariates. The demographic factors considered were sex, age, school type, subject specialisation, job title, committee membership, total years of teaching experience, years at the current school, years of managerial experience and years in a managerial role at the current school. School-level covariates included the number of classes and students, and workplace social capital (WSC). WSC was assessed using the validated 8-item WSC scale (Hori et al., 2019 ; Inoue et al., 2024 ; Kouvonen et al., 2006 ; Norikoshi et al., 2020 ; Suzuki et al., 2010 ). Responses were given on a 4-point Likert scale (1 = strongly disagree to 4 = strongly agree) and mean scores were calculated, with higher values indicating greater cohesion and trust. Statistical analysis Descriptive statistics were calculated for all variables. Means and standard deviations were computed for continuous variables, and frequencies and percentages were reported for categorical variables. Following all analyses were conducted at the school level using aggregated data. A two-step structural equation modeling (SEM) approach was applied to validate the J-HPSIQ and examine its theoretical structure (Anderson & Gerbing, 1988 ; Kline, 2016 ). In the first step (measurement model), confirmatory factor analysis (CFA) was performed to test whether the observed indicators adequately represented the seven hypothesized latent constructs—Adherence, Dose, Participant Responsiveness, Quality of Delivery, Integration, PD, and Adaptation. All latent constructs had at least two observed indicators, except for PD and Adaptation, which were modeled as single-indicator latent variables with fixed loadings (1.0) and error variances estimated from an assumed reliability of 0.70 (Bollen, 1989 ). Items with zero or near-zero variance were excluded. Guided by theoretical considerations and modification indices, a small number of within-construct correlated errors were permitted among conceptually related items (e.g., parallel or sequential questions), whereas cross-construct error covariances were not allowed (Kline, 2016 ). Parameters were estimated using maximum likelihood with missing values (MLMV), assuming data were missing at random and treating Likert-type items as approximately continuous. Model adequacy was evaluated using several indices: the chi-square statistic (χ²), comparative fit index (CFI), Tucker–Lewis index (TLI), and root mean square error of approximation (RMSEA), along with the Akaike (AIC) and Bayesian (BIC) information criteria. Acceptable model fit was defined as CFI and TLI ≥ 0.90 and RMSEA ≤ 0.08. Nested models incorporating theoretically justified correlated errors were compared using likelihood-ratio (LR) tests and changes in fit indices (ΔCFI, ΔTLI, ΔRMSEA, ΔAIC/BIC). Standardized factor loadings with 95% confidence intervals and the proportion of variance explained (R²) were reported. Convergent validity was assessed using composite reliability (CR) and average variance extracted (AVE), with thresholds of CR ≥ 0.70 and AVE ≥ 0.50 indicating adequacy. Discriminant validity was examined using both the Fornell–Larcker criterion—where the square root of each construct’s AVE exceeds its inter-construct correlations—and the heterotrait–monotrait (HTMT) ratio, with HTMT < 0.85 considered acceptable. Adjusted CR values accounting for correlated errors were also computed (Fornell & Larcker, 1981 ; Hair et al., 2022 ). Detailed model-fit indices, convergent validity results, and the Fornell–Larcker matrix are presented in Supplementary Materials (eTables 1 & 2). In the second step (structural model), the validated measurement model was used to test the structural relationships between latent constructs and to examine the concurrent validity of the J-HPSIQ. Specifically, school-level multiple linear regression analyses were conducted to assess the associations between SHDs’ health literacy on social determinants of health (SDH-HL) and J-HPSIQ implementation scores. Two models were estimated: Model 1 (unadjusted) and Model 2 (adjusted for SHD characteristics—sex, age, teaching experience, years in current role—and school-level covariates including WSC, school type, number of classes, and number of students). All continuous predictors were standardized before analysis. Regression coefficients (β) and 95% confidence intervals (CIs) were reported. Heteroskedasticity-consistent (HC3) robust standard errors were applied, and statistical significance was set at p < 0.05 (two-tailed). All analyses were conducted using Stata version 19.5 (StataCorp LLC, College Station, TX, USA). Results Table 1 presents the descriptive characteristics of participants and schools. A total of 1,295 school staff from 174 schools participated, including principals (n = 144), school management committee members (n = 779), SHDs (n = 114), health and physical education teachers (n = 161), and yogo teachers (n = 97). The mean age of SHDs was 50.2 years (SD = 9.9), with an average of 25.2 years of teaching experience and 4.1 years in their current role. At the school level, the mean total J-HPSIQ score was 1.8 ± 0.7. Among subscales, Participant Responsiveness (2.1 ± 0.8) and Adaptation (2.0 ± 0.9) showed the highest implementation levels, while Adherence was lowest (1.3 ± 0.7). Workplace social capital (WSC) scores were similar across occupational groups (mean ≈ 24.9). Table 1 Descriptive characteristics of participants and schools (n = 1,295) variable N mean / % SD Total # Principal 144 100.0 School Management Committee Members 779 100.0 SHD 114 100.0 Health & Physical Education teacher 161 100.0 Yogo teacher 97 100.0 Male Principal 125 86.8 School Management Committee Members 602 77.3 SHD 41 36.0 Yogo teacher 1 1.0 Health & Physical Education teacher 127 78.9 Female Principal 17 11.8 School Management Committee Members 157 20.2 SHD 69 60.5 Health & Physical Education teacher 34 21.1 Yogo teacher 94 96.9 No answer to sex Principal 2 1.4 School Management Committee Members 20 2.6 SHD 4 3.5 Health & Physical Education teacher 0 0.0 Yogo teacher 2 2.1 Age Health & Physical Education teacher 38.6 10.5 SHD 50.2 9.9 School Management Committee Members 50.3 8.2 Principal 59.0 1.6 Yogo teacher 41.7 10.7 Teaching experience of SHD (yrs) 25.2 10.6 Current-role experience of SHD (yrs) 4.1 5.4 J-HPSIS total score 114 1.8 0.7 Adaptation 114 2.0 0.9 Adherence 114 1.3 0.7 Dose 114 1.7 0.7 Participant Responsiveness 114 2.1 0.8 Integration 114 1.6 0.8 Program Differentiation 114 1.9 0.9 Quality of Delivery 114 1.6 0.9 SDH-HL (school level) 114 3.2 0.6 Workplace social capital Health & Physical Education teacher 85 24.9 1.6 SHD 114 24.9 1.9 School Management Committee Members 134 24.9 1.9 Principal 144 24.1 3.3 Yogo teacher 87 24.9 1.6 Values are school-level means (SD). SDH-HL = health literacy on social determinants of health; WSC = workplace social capital. SHD = school health director. Following the two-step SEM procedure, the hypothesized measurement model (CFA) comprising seven latent constructs—Adherence, Dose, Participant Responsiveness, Quality of Delivery, Integration, Program Differentiation, and Adaptation—was first evaluated. Of the original indicators, three items within the Adherence domain (wellbeing, media literacy, and hearing health) showed zero variance across schools and were excluded from analysis. The CFA yielded moderate-to-fair fit (χ²(619) = 1280.55, CFI = 0.773, TLI = 0.760, RMSEA = 0.097, AIC = 9934.26, BIC = 10265.34). Subsequently, a structural model was specified in which Adherence was regressed on Dose, Participant Responsiveness, Quality of Delivery, and Integration, reflecting the theoretical framework of program implementation. This model demonstrated improved fit (χ 2 (604) = 1069.62, CFI = 0.840, TLI = 0.820, RMSEA = 0.083, AIC = 9753.33, BIC = 10125.46). A likelihood-ratio test indicated that the structural model fit the data significantly better than the measurement model (Δχ 2 (15) = 211.0, p < 0.001), accompanied by an increase in CFI (+ 0.07) and a substantial reduction in AIC (− 180.93). Detailed model-fit indices for the CFA (measurement) and SEM (structural) models are provided in Supplementary eTable 1. Table 2 presents standardized factor loadings from the CFA of the J-HPSIQ. The proportion of variance explained (R²) for each latent factor ranged from 0.29 to 0.72. All standardized factor loadings were significant (0.34–0.87, p < 0.001). Composite reliability (CR) values exceeded 0.80, and adjusted CR values remained above 0.80 for all constructs. Average variance extracted (AVE) ranged from 0.36 to 0.63 (Table 3 ), supporting convergent validity. Discriminant validity was generally supported by the HTMT ratios (Table 4 ), with one pair (Adherence–Quality of Delivery) exceeding 0.85; additional evidence based on the Fornell–Larcker criterion is presented in Supplementary eTable 2, where the same pair violates the criterion. The largest inter-construct association was observed between Adherence and Quality of Delivery (HTMT = 0.884). Table 2 Standardized factor loadings for the seven-factor J-HPSIQ model (final SEM model) Factor Indicator Standardized Factor loading 95% CI Adherence Acted on evaluation findings 0.725 [0.615, 0.834] Annual evaluation of HPS initiatives 0.595 [0.462, 0.728] HPS coordination in place 0.74 [0.640, 0.841] Regular survey: hygiene / infection control 0.608 [0.478, 0.738] Regular survey: nutrition 0.5 [0.348, 0.652] Regular survey: physical activity 0.695 [0.586, 0.804] Regular survey: physical environment 0.523 [0.375, 0.670] Regular survey: relationships & sexuality 0.615 [0.487, 0.742] Regular survey: sleep 0.535 [0.391, 0.679] Regular survey: students requiring special support 0.539 [0.396, 0.682] Regular survey: tobacco/alcohol/drugs 0.336 [0.160, 0.513] Sufficient funding for HPS 0.597 [0.462, 0.732] Sufficient staff time for HPS 0.696 [0.580, 0.812] Dose Behavioral guidelines in place (staff/students/parents) 0.704 [0.597, 0.810] Early identification & discussion of student issues 0.561 [0.424, 0.698] Formal lessons implemented (health topics) 0.742 [0.648, 0.836] Policy includes topic: parents 0.822 [0.746, 0.899] Policy includes topic: staff 0.847 [0.780, 0.913] Policy includes topic: students 0.79 [0.703, 0.877] Supplementary activities (campaigns/trips/guests) 0.417 [0.255, 0.579] Participant Responsiveness Stakeholder participation: education board 0.634 [0.518, 0.750] Stakeholder participation: external advisors (public health/child services) 0.727 [0.634, 0.820] Stakeholder participation: external partners (physician/dentist/pharmacist) 0.749 [0.661, 0.836] Stakeholder participation: management 0.869 [0.816, 0.921] Stakeholder participation: parents 0.793 [0.719, 0.867] Stakeholder participation: school health coordinator 0.815 [0.745, 0.884] Stakeholder participation: students 0.823 [0.756, 0.889] Stakeholder participation: support staff 0.685 [0.580, 0.789] Stakeholder participation: teachers 0.843 [0.783, 0.903] Quality of Delivery Active communication: staff/students/parents 0.807 [0.731, 0.883] Core values/mission align with HPS 0.67 [0.556, 0.783] Health considered in activities/environment 0.801 [0.724, 0.878] Healthy choices encouraged in school 0.622 [0.496, 0.747] Staff are role models for health 0.828 [0.758, 0.897] Integration External experts' competence for HPS 0.845 [0.771, 0.920] Regular contact with external supporters 0.773 [0.684, 0.863] Teacher competence for HPS implementation 0.749 [0.653, 0.845] Program Differentiation 1.000 (Fixed) Adaptation 1.000 (Fixed) Factor loadings are completely standardized estimates from the final structural equation model (SEM). Program Differentiation and Adaptation were modeled as single-indicator latent variables with their loadings fixed to 1.00 and error variances constrained based on an assumed reliability of ρ = 0.70. All other latent constructs were identified by at least two observed indicators. Table 3 Convergent validity of the J-HPSIQ constructs Construct CR AVE CR_adj Adherence 0.877 0.362 0.819 Dose 0.874 0.507 0.811 Participant Responsiveness 0.930 0.599 0.927 Quality of Delivery 0.864 0.563 0.864 Integration 0.833 0.625 0.833 CR = composite reliability; AVE = average variance extracted; CR_adj = composite reliability adjusted for correlated errors. Table 4 Discriminant validity based on heterotrait–monotrait ratio of correlations. Adherence Dose Participant Responsiveness Quality of Delivery Integration Adherence 1 0.589 0.629 0.884 0.744 Dose 0.589 1 0.815 0.699 0.761 Participant Responsiveness 0.629 0.815 1 0.689 0.716 Quality of Delivery 0.884 0.699 0.689 1 0.812 Integration 0.744 0.761 0.716 0.812 1 Diagonal values = 1 by definition. Table 5 shows the associations of SHD health literacy with overall and domain-specific implementation of HPS activities. Multiple linear regression analyses revealed that higher SHDs’ SDH-HL scores were significantly associated with stronger overall HPS implementation (Model 1: β = 0.20, p < 0.001; Model 2: β = 0.21, p < 0.01), even after adjusting for workplace social capital, demographic, and school-level covariates. The adjusted model accounted for approximately 18% of the variance in total implementation (adjusted R² = 0.18). At the domain level, SDH-HL showed the strongest associations with Quality of Delivery (β = 0.47, p < 0.001), Integration (β = 0.23, p < 0.01), and Adaptation (β = 0.29, p < 0.01). Associations with Dose and Participant Responsiveness were smaller and non-significant for Adherence. Table 5 Associations of SHDs’ health literacy with overall and domain-specific HPS implementation (school-level regressions) HPS total Adherence Dose Participant Responsiveness β 95%CI β 95%CI β 95%CI β 95%CI β 95%CI β 95%CI β 95%CI β 95%CI Constant 1.456*** [1.352,1.559] 1.547*** [1.121,1.974] 1.226*** [1.106,1.346] 1.565*** [1.117,2.013] 1.720*** [1.598,1.842] 1.774*** [1.298,2.251] 1.616*** [1.460,1.772] 1.618*** [0.981,2.254] SDH-HL (z) 0.197*** [0.099,0.295] 0.209** [0.086,0.332] 0.238** [0.092,0.384] 0.241* [0.055,0.428] 0.102 [-0.032,0.235] 0.108 [-0.036,0.252] 0.162* [0.009,0.315] 0.172 [-0.010,0.354] WSC (z) 0.051 [-0.064,0.166] 0.085 [-0.026,0.196] 0.053 [-0.094,0.200] 0.004 [-0.183,0.191] Sex (SHD) -0.038 [-0.270,0.194] -0.204 [-0.455,0.048] -0.019 [-0.274,0.235] 0.065 [-0.270,0.400] Age 0.045 [-0.226,0.316] 0.06 [-0.255,0.376] 0.123 [-0.190,0.437] 0.346* [0.035,0.657] Teaching experience (SHD, z) 0.066 [-0.180,0.312] -0.036 [-0.347,0.276] 0.088 [-0.202,0.377] -0.229 [-0.504,0.046] Current role experience (SHD, z) -0.07 [-0.226,0.086] -0.054 [-0.221,0.113] -0.13 [-0.291,0.031] -0.083 [-0.318,0.152] Number of Classes (z) 0.084 [-0.110,0.278] 0.036 [-0.204,0.277] 0.073 [-0.133,0.279] 0.142 [-0.133,0.418] Number of Students (z) 0.028 [-0.141,0.198] 0.057 [-0.143,0.257] -0.009 [-0.204,0.186] -0.063 [-0.318,0.192] School type 1 ref ref ref ref School type 2 -0.01 [-0.451,0.432] 0.077 [-0.442,0.596] 0.062 [-0.417,0.540] -0.111 [-0.676,0.455] School type 3 -0.232 [-0.899,0.435] -0.012 [-0.874,0.850] -0.131 [-0.974,0.713] -0.687 [-1.817,0.444] Coefficients are school-level OLS estimates with HC3 robust SEs. SDH-HL (z) = standardized school-level health literacy on social determinants of health; WSC (z) = standardized workplace social capital. Reference = category reference for school type. p < 0.05, p < 0.01, p < 0.001. Table 5 continued Quality of Delivery Integration Program Differentiation Adaptation β 95%CI β 95%CI β 95%CI β 95%CI β 95%CI β 95%CI β 95%CI β 95%CI Constant 1.609*** [1.449,1.769] 1.946*** [1.287,2.605] 2.052*** [1.911,2.194] 2.047*** [1.492,2.601] 1.882*** [1.710,2.053] 1.737*** [1.027,2.446] 2.005*** [1.837,2.172] 2.169*** [1.466,2.872] SDH- HL (z) 0.421*** [0.282,0.560] 0.465*** [0.273,0.657] 0.214** [0.075,0.354] 0.229** [0.062,0.397] 0.270** [0.080,0.459] 0.270* [0.041,0.498] 0.271** [0.093,0.449] 0.287** [0.074,0.500] WSC (z) 0.063 [-0.101,0.227] 0.083 [-0.077,0.244] 0.099 [-0.071,0.269] 0.038 [-0.149,0.224] Sex (SHD) -0.164 [-0.510,0.182] 0.002 [-0.323,0.327] 0.107 [-0.295,0.510] 0 [-0.387,0.388] Age -0.063 [-0.530,0.404] -0.127 [-0.484,0.229] -0.03 [-0.368,0.307] -0.054 [-0.424,0.316] Teaching experience (SHD, z) 0.192 [-0.283,0.668] 0.212 [-0.096,0.520] 0.242 [-0.063,0.547] 0.181 [-0.171,0.532] Current role experience (SHD, z) -0.091 [-0.287,0.104] -0.069 [-0.307,0.169] -0.103 [-0.394,0.188] -0.09 [-0.371,0.192] Number of Classes (z) 0.223 [-0.054,0.500] 0.041 [-0.156,0.238] -0.061 [-0.404,0.281] 0.146 [-0.269,0.562] Number of Students (z) 0.045 [-0.223,0.313] 0.137 [-0.065,0.339] 0.004 [-0.270,0.278] 0.044 [-0.242,0.330] School type 1 ref ref ref ref School type 2 0.187 [-0.448,0.823] 0 [-0.597,0.598] -0.166 [-0.845,0.514] -0.399 [-1.054,0.255] School type 3 -0.582 [-1.742,0.578] 0.191 [-0.576,0.958] -0.055 [-1.290,1.181] -0.748 [-2.067,0.571] Coefficients are school-level OLS estimates with HC3 robust SEs. SDH-HL (z) = standardized school-level health literacy on social determinants of health; WSC (z) = standardized workplace social capital. Reference = category reference for school type. p < 0.05, p < 0.01, p < 0.001. Discussion This study demonstrated the construct and concurrent validity of the Japanese version of the Health‑Promoting School Implementation Questionnaire (J‑HPSIQ). The J-HPSIQ demonstrated a stable seven-factor structure with moderate-to-fair fit and high internal consistency (CR > 0.80). Although the initial CFA reproduced the original seven-domain structure (Vennegoor et al., 2023 ), overall fit was only moderate; subsequent SEM that modeled Adherence as an outcome predicted by Dose, Participant Responsiveness, Quality of Delivery, and Integration yielded substantially improved fit. One notable exception was the Adherence–Quality of Delivery pair, which exceeded the HTMT threshold and did not satisfy the Fornell–Larcker criterion, suggesting partial conceptual overlap (Fornell & Larcker, 1981 ; Hair et al., 2022 ). This pattern indicates that in Japanese schools procedural adherence and perceived delivery quality often coincide, as both may be regarded as indicators of professionalism and accountability. At the school level, higher SDH-HL among SHDs was positively associated with overall implementation and, in particular, with the domains of Quality of Delivery, Integration, and Adaptation, whereas associations with Adherence were small or nonsignificant. These findings are consistent with the European validation of the original HPSIQ (Vennegoor et al., 2023 ) and with research linking organizational health literacy to the quality and sustainability of implementation (Dadaczynski et al., 2020 ; Sørensen et al., 2012 ). In Japan’s highly standardized school health system—where compliance with policy mandates is embedded in administrative routines—adherence functions largely as a baseline requirement rather than a marker of excellence (Japan School Health Association, 2020 ; Tomokawa, Shirakawa, et al., 2021). SHDs occupy a pivotal role within this system: they coordinate health policy, facilitate staff collaboration, and liaise with external professionals such as school physicians and pharmacists (Japan School Health Association, 2020 ). Their ability to interpret information and foster coordination helps determine how schools translate national standards into context-specific and collaborative practice. Consequently, variation in SHDs’ SDH-HL may influence how effectively schools integrate health promotion into daily operations and respond to community needs. The modest discriminant validity between Adherence and Quality of Delivery may further reflect Japan’s administrative culture, in which procedural correctness and performance quality are closely intertwined. Within this framework, schools that demonstrate procedural thoroughness are also perceived as delivering high-quality practice, blurring the conceptual boundary between compliance and quality. Clarifying this distinction in future applications—by emphasizing qualitative aspects of delivery such as participatory decision-making, staff engagement, and reflective evaluation—could enhance interpretability without altering the instrument’s underlying structure. The J-HPSIQ retained the conceptual integrity of the original tool while revealing contextual nuances in how implementation domains interrelate. These nuances likely stem from Japan’s institutional configuration, where specialized roles (e.g., yogo teachers, school physicians, and pharmacists) and centralized governance define the structure of school health activities (Japan School Health Association, 2020 ; Tomokawa, Miyake, et al., 2021). Yogo teachers manage daily health guidance and student monitoring, while external professionals provide mandated oversight and technical guidance (Tomokawa et al., 2020 ; Tomokawa, Shirakawa, et al., 2021). This multilayered governance structure ensures procedural rigor and accountability but tends to limit bottom-up flexibility. As a result, schools in Japan exhibit Japan-specific patterns of coordination and adaptation—characterized by hierarchical decision-making and role specialization—compared with the more participatory approaches observed in decentralized education systems. The observed associations between SHDs’ SDH-HL and the domains of Quality of Delivery, Integration, and Adaptation underscore the importance of organizational health literacy within leadership roles. Although causal inference cannot be drawn from this cross-sectional design, SHDs with stronger literacy regarding the social determinants of health may be better able to interpret contextual factors, mobilize collaboration, and align school initiatives with local priorities. Professional development programs that integrate social-determinants thinking into school management and teacher training could therefore strengthen schools’ capacity for equitable and context-responsive implementation of the HPS framework (Jourdan et al., 2016 ; Samdal & Rowling, 2011 ). Policymakers may also employ the J-HPSIQ as a diagnostic tool to monitor implementation progress and to guide targeted capacity-building at prefectural or national levels. This study has several strengths, including the large, multi-occupational sample, rigorous translation and cultural adaptation process, and integration of both individual- and school-level covariates. The J-HPSIQ also demonstrated consistent reliability and theoretically coherent construct validity within the Japanese school context. However, several limitations should be acknowledged. First, the sample was limited to prefectural high and special-needs schools within a single prefecture. Although this yielded a relatively large and organizationally homogeneous dataset, the findings may not generalize to other regions or to different school types, particularly elementary and junior high schools where health promotion activities are often more systematically institutionalized. Broader validation across diverse educational settings is therefore recommended. Second, the cross-sectional design limits interpretation regarding temporal stability or predictive validity. Longitudinal or repeated-measure studies are needed to assess score stability over time and to evaluate the instrument’s utility for monitoring and guiding Health-Promoting School initiatives. Finally, all measures relied on self-report data, which may introduce social-desirability or common-method bias, although anonymity and multi-role participation likely mitigated this risk. Despite these limitations, the study provides a robust foundation for future longitudinal and multi-site validation of the J-HPSIQ. Conclusions The J-HPSIQ demonstrated satisfactory reliability and validity for assessing school-level implementation of the Health-Promoting School framework in Japan. The observed associations between SHDs’ health literacy and key implementation domains highlight the relevance of organizational literacy for promoting effective, adaptive, and equity-oriented school health systems, while underscoring the value of capacity building within school leadership. Declarations Author statements Acknowledgements The authors would like to thank all teachers who agreed to participate in this study. Ethical approval The study was approved by the Ethics Committee of the Graduate School of Human Development and Environment, Kobe University (approval number 685-3; revision-685-3). Data availability The J-HPSIQ validated in this study will be considered for open release after further validation studies are completed. At this stage, the scale can be provided upon reasonable request to the corresponding author. Funding This study was supported by Grants-in-Aid for Scientific Research (JSPSKAKENHI Grant Number JP24K00395) from the Japan Society for the Promotion of Science. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Competing interests The authors declare no other conflict of interests. Authors contribution All authors contributed to the concept or design of the study, the acquisition, analysis, or interpretation of data for the work. A.K. drafted the manuscript. K.M and M.T. critically revised the manuscript. All authors gave final approval and agreed to be accountable for all aspects of work, thus ensuring integrity and accuracy. Declaration of generative AI and AI-assisted technologies in the manuscript preparation process During the preparation of this work the authors used ChatGPT (OpenAI) in order to assist with language editing and improving clarity of expression. After using this tool, the author(s) reviewed and edited the content as needed and take full responsibility for the content of the published article. References Anderson, J. C., & Gerbing, D. W. (1988). Structural equation modeling in practice: A review and recommended two-step approach. Psychological Bulletin , 103 (3), 411–423. 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Health screening system to ensure the children’ health and development in Japan. Pediatrics International: Official Journal of the Japan Pediatric Society , ed.14733-ped.14733. Tomokawa, S., Shirakawa, Y., Miyake, K., Ueno, M., Koiso, T., & Asakura, T. (2021). Lessons learned from health education in Japanese schools. Pediatrics International: Official Journal of the Japan Pediatric Society , 63 (6), 619–630. Vennegoor, G., Van Assema, P., Eekhout, I., Lezwijn, J., Molleman, G., & Jansen, M. (2023). Measuring Implementation of Health Promoting School (HPS) Programs: Development and Psychometric Evaluation of the HPS Implementation Questionnaire. The Journal of School Health , 93 (6), 450–463. World Health Organization and the UNESCO. (2021). Making every school a health-promoting school: implementation guidance. The Lancet Child and Adolescent Health , 5 (8), 539–540. Wourld Health Organization. (2000). Local action: creating health promoting schools . https://www.who.int/publications/i/item/local-action-creating-health-promoting-schools Additional Declarations No competing interests reported. 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recognized as a cornerstone of population health and health equity. The World Health Organization\u0026rsquo;s (WHO) Health-Promoting School (HPS) framework represents a paradigmatic shift from individual health education toward a whole-school approach that embeds health within the educational mission, organizational structures, and everyday ethos of schools (\u003cem\u003eMaking every school a health-promoting school \u0026ndash; Global standards and indicators\u003c/em\u003e, 2021; World Health Organization and the UNESCO, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This framework reconceptualizes the school as a key setting for shaping lifelong health behaviors and fostering social inclusion. It rests on six interdependent pillars: (1) comprehensive health education, (2) a safe and supportive environment, (3) access to school health services, (4) family and community partnerships, (5) the development of coherent health policies, and (6) organizational capacity for health promotion (Wourld Health Organization, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). A growing body of meta-analytic evidence demonstrates that the HPS approach improves diverse adolescent outcomes\u0026mdash;including diet, physical activity, substance use, and mental well-being\u0026mdash;across varied sociocultural contexts (Goldberg et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Langford et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Lekamge et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Accordingly, the HPS framework has evolved into a global reference model for equity-oriented, school-based health promotion.\u003c/p\u003e\u003cp\u003eDespite this evidence base, systematic tools for assessing the \u003cem\u003edepth and quality\u003c/em\u003e of HPS implementation within schools remain limited. As noted by Kazemitabar et al., only 7 of 649 HPS-related studies examined psychometric properties, revealing a striking absence of validated metrics capable of capturing organizational and cultural dimensions of implementation (Kazemitabar et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). To fill this gap, Vennegoor et al. developed the \u003cem\u003eHealth-Promoting School Implementation Questionnaire (HPSIQ)\u003c/em\u003e\u0026mdash;a theoretically grounded, 28-item instrument designed to appraise school-level enactment of HPS principles across domains such as policy, environment, pedagogy, community partnerships, and evaluation (Vennegoor et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The HPSIQ demonstrated sound factorial validity and strong internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.71\u0026ndash;.91), and has since been adopted across Europe as a diagnostic tool for guiding system-wide health promotion and educational reform. Nevertheless, the cross-cultural transferability of the HPSIQ has not been rigorously tested. Implementation of HPS principles is mediated by national education systems, professional norms, and institutional logics, and therefore requires validation within diverse governance and cultural frameworks.\u003c/p\u003e\u003cp\u003eJapan, with its highly institutionalized school health system, provides a particularly instructive case. Japan\u0026rsquo;s school health system is anchored in a dense legal and administrative architecture that integrates health legislation, specialized personnel, national curricula, and formal coordination mechanisms (Tomokawa et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Its statutory foundations\u0026mdash;the \u003cem\u003eSchool Education Act\u003c/em\u003e and the \u003cem\u003eSchool Health and Safety Act\u003c/em\u003e\u0026mdash;mandate periodic health examinations, infection control, environmental hygiene management, and health instruction. These policies guarantee a national minimum standard for school health practice. Within this framework, the Ministry of Education, Culture, Sports, Science and Technology (MEXT) defines three operational domains: health education, health management, and health organizational activities (Tomokawa, Shirakawa, et al., 2021). Health education cultivates students\u0026rsquo; knowledge and behaviors through the health and physical education curriculum and guidance from licensed school nurse teachers (\u003cem\u003eyogo\u003c/em\u003e teachers). Health management encompasses daily monitoring, medical examinations, and infection control led by \u003cem\u003eyogo\u003c/em\u003e teachers in collaboration with classroom teachers and parents. Health organizational activities include school health planning, teacher training, and intersectoral coordination managed by the school health director (\u003cem\u003ehoken shuji, SHD\u003c/em\u003e). A distinctive institutional feature is the statutory involvement of the three school health professionals\u0026mdash;school physicians, dentists, and pharmacists (\u003cem\u003e\u0026ldquo;gakkō sanshi\u0026rdquo;\u003c/em\u003e). These professionals provide expertise in medical oversight, environmental hygiene, and health education, and their participation in school health committees institutionalizes collaboration between schools and external health systems (Tomokawa, Miyake, et al., 2021). This tripartite system is remarkably rare in global practice, reflecting Japan\u0026rsquo;s historically hybrid model of education and public health governance. While Japan\u0026rsquo;s system aligns structurally with HPS principles, empirical evidence regarding its \u003cem\u003efunctional alignment\u003c/em\u003e\u0026mdash;that is, the extent to which schools operationalize these mandates as a holistic HPS approach\u0026mdash;remains limited (Japan School Health Association, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Formal compliance (e.g., mandated committees, policy documents) may not necessarily translate into substantive integration of health promotion within curricula, professional practice, or community partnerships. This implementation gap underscores the need for validated, context-sensitive instruments capable of mapping how institutional structures are enacted as lived practices within schools.\u003c/p\u003e\u003cp\u003eTo address both the need for cross-cultural validation of the Health-Promoting School Implementation Questionnaire (HPSIQ) and the need for a contextually grounded instrument to assess the implementation of school health activities in Japan, this study examined the psychometric validity of the Japanese version (J-HPSIQ). Specifically, we (1) tested its factorial structure using confirmatory factor analysis and (2) assessed its concurrent validity in relation to SHDs\u0026rsquo; health literacy on social determinants of health (SDH-HL).\u003c/p\u003e\u003cp\u003eIn this study, SDH-HL was conceptualized as the concurrent construct, extending the notion of health literacy to the structural and societal domains. It encompasses the capacity to recognize, critically appraise, and act upon the social, economic, and environmental conditions that shape health inequities(Matsumoto \u0026amp; Nakayama, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). By emphasizing critical awareness of systemic determinants and the ability to translate such understanding into equity-oriented action, SDH-HL provides a framework for understanding how educators and administrators engage with and respond to the broader determinants of health within institutional settings. More broadly, health literacy (HL) has been recognized as a foundational determinant of health behavior, empowerment, and equity across public-health and educational systems. The integrated model proposed by S\u0026oslash;rensen et al. defines HL as the ability to access, understand, appraise, and apply health information to make informed decisions regarding health promotion, disease prevention, and care (S\u0026oslash;rensen et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Importantly, HL is not viewed as a fixed cognitive ability but as a context-embedded social practice, shaped by cultural, institutional, and environmental conditions that influence how individuals and organizations interact with health information. Within schools, HL\u0026mdash;and particularly SDH-HL\u0026mdash;serves as the cognitive, ethical, and organizational foundation for implementing the Health-Promoting School (HPS) framework, which integrates inclusive education, supportive environments, and intersectoral collaboration. Empirical evidence supports this linkage: Dadaczynski et al. demonstrated that limited HL among school leaders was associated with lower levels of HPS implementation, even after adjusting for attitudes, competencies, and demographic factors (Dadaczynski et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) Together, these insights indicate that HL functions not only as an individual capability but also as an organizational capacity that enables the integration of health promotion into school governance and practice. Accordingly, examining the relationship between SHDs\u0026rsquo; SDH-HL and the degree of HPS implementation provides a theoretically grounded test of the concurrent validity of the J-HPSIQ and advances understanding of how equity-oriented health literacy operates as a structural driver of health-promoting education systems.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eThe target population comprised all 175 prefectural schools (148 general, vocational, or university-affiliated high schools; 27 special needs schools) in a large prefecture of western Japan encompassing both urbanized coastal areas and rural mountainous regions (population approximately 5.4\u0026nbsp;million). Because the Japanese school system is nationally standardized by the Ministry of Education, Culture, Sports, Science and Technology (MEXT)\u0026mdash;with uniform curricula, staffing structures, and school health regulations\u0026mdash;the participating schools can be regarded as broadly representative of the organizational context of Japanese secondary education. One school was excluded because a member of the research team (KM) was employed there, leaving 174 schools eligible.\u003c/p\u003e\u003cp\u003eRecruitment targeted staff with primary responsibility for school health activities, including principals, heads of the health division SHDs, school management committee members (mainly section heads), \u003cem\u003eyogo\u003c/em\u003e teachers, and health and physical education teachers. Because organizational structures vary and faculty may hold multiple roles, the exact denominator was indeterminate. A total of 1,295 staff members provided complete data and were included in the analysis (principals, n\u0026thinsp;=\u0026thinsp;144; school management committee members, n\u0026thinsp;=\u0026thinsp;779; SHDs, n\u0026thinsp;=\u0026thinsp;114; health and physical education teachers, n\u0026thinsp;=\u0026thinsp;161; yogo teachers, n\u0026thinsp;=\u0026thinsp;97). Unlike our previous validation focused solely on high schools, the present HPSIQ validation included both high schools and special needs schools to reflect the heterogeneity of school health service delivery in Japan.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003ePrior to data collection, the study protocol was presented to and approved by the Board of the Prefectural School Principals Association. Survey invitations and study information were emailed to each principal. Data were collected between November and December 2023 using an anonymous, self-administered web-based questionnaire (\u0026asymp;\u0026thinsp;20 minutes). Up to three email reminders were sent before the response deadline. Electronic written informed consent was obtained from all participants prior to participation (participants indicated consent by selecting an \u0026ldquo;I agree\u0026rdquo; checkbox before accessing the questionnaire), with assurances of anonymity. All participants were adult school staff; therefore, consent from legal guardians was not required. All methods were performed in accordance with the Declaration of Helsinki and with the Ethical Guidelines for Medical and Biological Research Involving Human Subjects in Japan (MEXT/MHLW/METI), and were approved by the Ethics Committee of the Graduate School of Human Development and Environment, Kobe University (approval No. 685-3; revision-685-3).\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eDevelopment of the Japanese Health-Promoting School Implementation Questionnaire (J-HPSIQ)\u003c/h2\u003e\u003cp\u003eThe J-HPSIQ was developed to assess the degree of school-level implementation of the Health-Promoting School (HPS) framework in Japan. Adaptation from the Dutch \u003cem\u003eHealthy School Questionnaire\u003c/em\u003e (Vennegoor et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) followed a forward\u0026ndash;backward translation procedure. Two experts in school health/public health (AK, KM) reviewed content validity and cultural relevance, and a pilot test with school management committee members, health and physical education teachers, and yogo teachers confirmed clarity. The final J-HPSIQ comprised 28 items across seven domains: Adherence, Dose, Participant Responsiveness, Quality of Delivery, Integration, Program Differentiation (PD), and Adaptation. Items were scored on a 0\u0026ndash;4 Likert scale (0\u0026thinsp;=\u0026thinsp;not at all to 4\u0026thinsp;=\u0026thinsp;to a very great extent); higher scores indicate greater implementation. Subscale and total scores were calculated as the mean of available items.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eHealth Literacy on Social Determinants of Health (SDH-HL)\u003c/h3\u003e\n\u003cp\u003eThe explanatory variable was staff health literacy regarding social determinants of health, measured using the Health Literacy on Social Determinants of Health Questionnaire (HL-SDHQ) (33 items; domains: access, understanding, appraisal, application)(Matsumoto \u0026amp; Nakayama, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Example items include \u0026ldquo;Finding people who are socially isolated and in poor health,\u0026rdquo; \u0026ldquo;Understanding that people with lower income are more likely to become ill,\u0026rdquo; and \u0026ldquo;Judging what kinds of social inequalities exist in leading a healthy life.\u0026rdquo; Response options were \u0026ldquo;very easy,\u0026rdquo; \u0026ldquo;fairly easy,\u0026rdquo; \u0026ldquo;fairly difficult,\u0026rdquo; \u0026ldquo;very difficult,\u0026rdquo; \u0026ldquo;don\u0026rsquo;t know/not applicable.\u0026rdquo; Scoring followed prior work: 4, 3, 2, 1 points for the four ordered responses; \u0026ldquo;don\u0026rsquo;t know/not applicable\u0026rdquo; was replaced with the item mean among all respondents (Matsumoto \u0026amp; Nakayama, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). All participating staff completed the HL-SDHQ; no missing data were observed. For each school, item-level means were averaged across staff and then summed over 33 items to yield a school-level total score (range 33\u0026ndash;132); higher scores reflect greater SDH-related health literacy.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eCovariates\u003c/h2\u003e\u003cp\u003eDemographic and occupational characteristics were used as covariates. The demographic factors considered were sex, age, school type, subject specialisation, job title, committee membership, total years of teaching experience, years at the current school, years of managerial experience and years in a managerial role at the current school. School-level covariates included the number of classes and students, and workplace social capital (WSC). WSC was assessed using the validated 8-item WSC scale (Hori et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Inoue et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Kouvonen et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Norikoshi et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Suzuki et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Responses were given on a 4-point Likert scale (1\u0026thinsp;=\u0026thinsp;strongly disagree to 4\u0026thinsp;=\u0026thinsp;strongly agree) and mean scores were calculated, with higher values indicating greater cohesion and trust.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics were calculated for all variables. Means and standard deviations were computed for continuous variables, and frequencies and percentages were reported for categorical variables.\u003c/p\u003e\u003cp\u003eFollowing all analyses were conducted at the school level using aggregated data. A two-step structural equation modeling (SEM) approach was applied to validate the J-HPSIQ and examine its theoretical structure (Anderson \u0026amp; Gerbing, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1988\u003c/span\u003e; Kline, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). In the first step (measurement model), confirmatory factor analysis (CFA) was performed to test whether the observed indicators adequately represented the seven hypothesized latent constructs\u0026mdash;Adherence, Dose, Participant Responsiveness, Quality of Delivery, Integration, PD, and Adaptation. All latent constructs had at least two observed indicators, except for PD and Adaptation, which were modeled as single-indicator latent variables with fixed loadings (1.0) and error variances estimated from an assumed reliability of 0.70 (Bollen, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1989\u003c/span\u003e). Items with zero or near-zero variance were excluded. Guided by theoretical considerations and modification indices, a small number of within-construct correlated errors were permitted among conceptually related items (e.g., parallel or sequential questions), whereas cross-construct error covariances were not allowed (Kline, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Parameters were estimated using maximum likelihood with missing values (MLMV), assuming data were missing at random and treating Likert-type items as approximately continuous. Model adequacy was evaluated using several indices: the chi-square statistic (χ\u0026sup2;), comparative fit index (CFI), Tucker\u0026ndash;Lewis index (TLI), and root mean square error of approximation (RMSEA), along with the Akaike (AIC) and Bayesian (BIC) information criteria. Acceptable model fit was defined as CFI and TLI\u0026thinsp;\u0026ge;\u0026thinsp;0.90 and RMSEA\u0026thinsp;\u0026le;\u0026thinsp;0.08. Nested models incorporating theoretically justified correlated errors were compared using likelihood-ratio (LR) tests and changes in fit indices (ΔCFI, ΔTLI, ΔRMSEA, ΔAIC/BIC). Standardized factor loadings with 95% confidence intervals and the proportion of variance explained (R\u0026sup2;) were reported. Convergent validity was assessed using composite reliability (CR) and average variance extracted (AVE), with thresholds of CR\u0026thinsp;\u0026ge;\u0026thinsp;0.70 and AVE\u0026thinsp;\u0026ge;\u0026thinsp;0.50 indicating adequacy. Discriminant validity was examined using both the Fornell\u0026ndash;Larcker criterion\u0026mdash;where the square root of each construct\u0026rsquo;s AVE exceeds its inter-construct correlations\u0026mdash;and the heterotrait\u0026ndash;monotrait (HTMT) ratio, with HTMT\u0026thinsp;\u0026lt;\u0026thinsp;0.85 considered acceptable. Adjusted CR values accounting for correlated errors were also computed (Fornell \u0026amp; Larcker, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1981\u003c/span\u003e; Hair et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Detailed model-fit indices, convergent validity results, and the Fornell\u0026ndash;Larcker matrix are presented in Supplementary Materials (eTables 1 \u0026amp; 2).\u003c/p\u003e\u003cp\u003eIn the second step (structural model), the validated measurement model was used to test the structural relationships between latent constructs and to examine the concurrent validity of the J-HPSIQ. Specifically, school-level multiple linear regression analyses were conducted to assess the associations between SHDs\u0026rsquo; health literacy on social determinants of health (SDH-HL) and J-HPSIQ implementation scores. Two models were estimated: Model 1 (unadjusted) and Model 2 (adjusted for SHD characteristics\u0026mdash;sex, age, teaching experience, years in current role\u0026mdash;and school-level covariates including WSC, school type, number of classes, and number of students). All continuous predictors were standardized before analysis. Regression coefficients (β) and 95% confidence intervals (CIs) were reported. Heteroskedasticity-consistent (HC3) robust standard errors were applied, and statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (two-tailed).\u003c/p\u003e\u003cp\u003eAll analyses were conducted using Stata version 19.5 (StataCorp LLC, College Station, TX, USA).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the descriptive characteristics of participants and schools. A total of 1,295 school staff from 174 schools participated, including principals (n\u0026thinsp;=\u0026thinsp;144), school management committee members (n\u0026thinsp;=\u0026thinsp;779), SHDs (n\u0026thinsp;=\u0026thinsp;114), health and physical education teachers (n\u0026thinsp;=\u0026thinsp;161), and yogo teachers (n\u0026thinsp;=\u0026thinsp;97). The mean age of SHDs was 50.2 years (SD\u0026thinsp;=\u0026thinsp;9.9), with an average of 25.2 years of teaching experience and 4.1 years in their current role. At the school level, the mean total J-HPSIQ score was 1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7. Among subscales, Participant Responsiveness (2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8) and Adaptation (2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9) showed the highest implementation levels, while Adherence was lowest (1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7). Workplace social capital (WSC) scores were similar across occupational groups (mean\u0026thinsp;\u0026asymp;\u0026thinsp;24.9).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive characteristics of participants and schools (n\u0026thinsp;=\u0026thinsp;1,295)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003evariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003emean / %\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal #\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrincipal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e144\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSchool Management Committee Members\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e779\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSHD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth \u0026amp; Physical Education teacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e161\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYogo teacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e100.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrincipal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e125\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSchool Management Committee Members\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e602\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e77.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSHD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYogo teacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth \u0026amp; Physical Education teacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e127\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e78.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrincipal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSchool Management Committee Members\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e157\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSHD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth \u0026amp; Physical Education teacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYogo teacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e96.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eNo answer to sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrincipal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSchool Management Committee Members\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSHD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth \u0026amp; Physical Education teacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYogo teacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth \u0026amp; Physical Education teacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSHD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSchool Management Committee Members\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrincipal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e59.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYogo teacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e41.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTeaching experience of SHD (yrs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCurrent-role experience of SHD (yrs)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJ-HPSIS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003etotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdaptation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdherence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParticipant Responsiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntegration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProgram Differentiation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQuality of Delivery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSDH-HL (school level)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eWorkplace social capital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth \u0026amp; Physical Education teacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSHD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e114\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSchool Management Committee Members\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e134\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrincipal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e144\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYogo teacher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eValues are school-level means (SD). SDH-HL\u0026thinsp;=\u0026thinsp;health literacy on social determinants of health; WSC\u0026thinsp;=\u0026thinsp;workplace social capital. SHD\u0026thinsp;=\u0026thinsp;school health director.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFollowing the two-step SEM procedure, the hypothesized measurement model (CFA) comprising seven latent constructs\u0026mdash;Adherence, Dose, Participant Responsiveness, Quality of Delivery, Integration, Program Differentiation, and Adaptation\u0026mdash;was first evaluated. Of the original indicators, three items within the Adherence domain (wellbeing, media literacy, and hearing health) showed zero variance across schools and were excluded from analysis. The CFA yielded moderate-to-fair fit (χ\u0026sup2;(619)\u0026thinsp;=\u0026thinsp;1280.55, CFI\u0026thinsp;=\u0026thinsp;0.773, TLI\u0026thinsp;=\u0026thinsp;0.760, RMSEA\u0026thinsp;=\u0026thinsp;0.097, AIC\u0026thinsp;=\u0026thinsp;9934.26, BIC\u0026thinsp;=\u0026thinsp;10265.34). Subsequently, a structural model was specified in which Adherence was regressed on Dose, Participant Responsiveness, Quality of Delivery, and Integration, reflecting the theoretical framework of program implementation. This model demonstrated improved fit (χ\u003csup\u003e2\u003c/sup\u003e (604)\u0026thinsp;=\u0026thinsp;1069.62, CFI\u0026thinsp;=\u0026thinsp;0.840, TLI\u0026thinsp;=\u0026thinsp;0.820, RMSEA\u0026thinsp;=\u0026thinsp;0.083, AIC\u0026thinsp;=\u0026thinsp;9753.33, BIC\u0026thinsp;=\u0026thinsp;10125.46). A likelihood-ratio test indicated that the structural model fit the data significantly better than the measurement model (Δχ\u003csup\u003e2\u003c/sup\u003e (15)\u0026thinsp;=\u0026thinsp;211.0, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), accompanied by an increase in CFI (+\u0026thinsp;0.07) and a substantial reduction in AIC (\u0026minus;\u0026thinsp;180.93). Detailed model-fit indices for the CFA (measurement) and SEM (structural) models are provided in Supplementary eTable 1. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents standardized factor loadings from the CFA of the J-HPSIQ. The proportion of variance explained (R\u0026sup2;) for each latent factor ranged from 0.29 to 0.72. All standardized factor loadings were significant (0.34\u0026ndash;0.87, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Composite reliability (CR) values exceeded 0.80, and adjusted CR values remained above 0.80 for all constructs. Average variance extracted (AVE) ranged from 0.36 to 0.63 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), supporting convergent validity. Discriminant validity was generally supported by the HTMT ratios (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e), with one pair (Adherence\u0026ndash;Quality of Delivery) exceeding 0.85; additional evidence based on the Fornell\u0026ndash;Larcker criterion is presented in Supplementary eTable 2, where the same pair violates the criterion. The largest inter-construct association was observed between Adherence and Quality of Delivery (HTMT\u0026thinsp;=\u0026thinsp;0.884).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStandardized factor loadings for the seven-factor J-HPSIQ model (final SEM model)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFactor\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndicator\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStandardized Factor loading\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eAdherence\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eActed on evaluation findings\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.725\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.615, 0.834]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnnual evaluation of HPS initiatives\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.595\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.462, 0.728]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHPS coordination in place\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.640, 0.841]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegular survey: hygiene / infection control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.608\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.478, 0.738]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegular survey: nutrition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.348, 0.652]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegular survey: physical activity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.695\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.586, 0.804]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegular survey: physical environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.523\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.375, 0.670]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegular survey: relationships \u0026amp; sexuality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.615\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.487, 0.742]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegular survey: sleep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.535\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.391, 0.679]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegular survey: students requiring special support\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.539\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.396, 0.682]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegular survey: tobacco/alcohol/drugs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.336\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.160, 0.513]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSufficient funding for HPS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.597\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.462, 0.732]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSufficient staff time for HPS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.696\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.580, 0.812]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBehavioral guidelines in place (staff/students/parents)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.704\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.597, 0.810]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEarly identification \u0026amp; discussion of student issues\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.561\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.424, 0.698]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFormal lessons implemented (health topics)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.742\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.648, 0.836]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePolicy includes topic: parents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.822\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.746, 0.899]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePolicy includes topic: staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.847\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.780, 0.913]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePolicy includes topic: students\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.703, 0.877]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSupplementary activities (campaigns/trips/guests)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.417\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.255, 0.579]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eParticipant Responsiveness\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStakeholder participation: education board\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.634\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.518, 0.750]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStakeholder participation: external advisors (public health/child services)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.727\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.634, 0.820]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStakeholder participation: external partners (physician/dentist/pharmacist)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.749\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.661, 0.836]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStakeholder participation: management\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.869\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.816, 0.921]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStakeholder participation: parents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.793\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.719, 0.867]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStakeholder participation: school health coordinator\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.815\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.745, 0.884]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStakeholder participation: students\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.823\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.756, 0.889]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStakeholder participation: support staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.685\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.580, 0.789]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStakeholder participation: teachers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.843\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.783, 0.903]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eQuality of Delivery\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eActive communication: staff/students/parents\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.807\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.731, 0.883]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCore values/mission align with HPS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.556, 0.783]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealth considered in activities/environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.801\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.724, 0.878]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHealthy choices encouraged in school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.622\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.496, 0.747]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStaff are role models for health\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.828\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.758, 0.897]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eIntegration\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExternal experts' competence for HPS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.845\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.771, 0.920]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegular contact with external supporters\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.773\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.684, 0.863]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTeacher competence for HPS implementation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.749\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e[0.653, 0.845]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eProgram Differentiation\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(Fixed)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eAdaptation\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(Fixed)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFactor loadings are completely standardized estimates from the final structural equation model (SEM). Program Differentiation and Adaptation were modeled as single-indicator latent variables with their loadings fixed to 1.00 and error variances constrained based on an assumed reliability of ρ\u0026thinsp;=\u0026thinsp;0.70. All other latent constructs were identified by at least two observed indicators.\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eConvergent validity of the J-HPSIQ constructs\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConstruct\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCR\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAVE\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCR_adj\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eAdherence\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.877\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.362\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.819\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.874\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.507\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.811\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eParticipant Responsiveness\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.930\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.599\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.927\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eQuality of Delivery\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.864\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.563\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.864\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eIntegration\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.833\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.625\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.833\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eCR\u0026thinsp;=\u0026thinsp;composite reliability; AVE\u0026thinsp;=\u0026thinsp;average variance extracted; CR_adj\u0026thinsp;=\u0026thinsp;composite reliability adjusted for correlated errors.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDiscriminant validity based on heterotrait\u0026ndash;monotrait ratio of correlations.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eAdherence\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDose\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003eParticipant Responsiveness\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003eQuality of Delivery\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003eIntegration\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eAdherence\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.589\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.629\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.884\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.744\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.589\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.815\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.699\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.761\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eParticipant Responsiveness\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.629\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.815\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.689\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.716\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eQuality of Delivery\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.884\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.699\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.689\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.812\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eIntegration\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.744\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.761\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.716\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.812\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eDiagonal values\u0026thinsp;=\u0026thinsp;1 by definition.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows the associations of SHD health literacy with overall and domain-specific implementation of HPS activities. Multiple linear regression analyses revealed that higher SHDs\u0026rsquo; SDH-HL scores were significantly associated with stronger overall HPS implementation (Model 1: β\u0026thinsp;=\u0026thinsp;0.20, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Model 2: β\u0026thinsp;=\u0026thinsp;0.21, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), even after adjusting for workplace social capital, demographic, and school-level covariates. The adjusted model accounted for approximately 18% of the variance in total implementation (adjusted R\u0026sup2; = 0.18). At the domain level, SDH-HL showed the strongest associations with Quality of Delivery (β\u0026thinsp;=\u0026thinsp;0.47, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Integration (β\u0026thinsp;=\u0026thinsp;0.23, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and Adaptation (β\u0026thinsp;=\u0026thinsp;0.29, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Associations with Dose and Participant Responsiveness were smaller and non-significant for Adherence.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociations of SHDs\u0026rsquo; health literacy with overall and domain-specific HPS implementation (school-level regressions)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"20\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c20\" colnum=\"20\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eHPS total\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e\u003cp\u003eAdherence\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c15\" namest=\"c12\"\u003e\u003cp\u003eDose\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c20\" namest=\"c17\"\u003e\u003cp\u003eParticipant Responsiveness\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConstant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.456***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[1.352,1.559]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.547***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[1.121,1.974]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.226***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e[1.106,1.346]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.565***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[1.117,2.013]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1.720***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e[1.598,1.842]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e1.774***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[1.298,2.251]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e1.616***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e[1.460,1.772]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e1.618***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[0.981,2.254]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSDH-HL (z)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.197***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[0.099,0.295]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.209**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[0.086,0.332]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.238**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e[0.092,0.384]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.241*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[0.055,0.428]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.102\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e[-0.032,0.235]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.036,0.252]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e0.162*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e[0.009,0.315]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e0.172\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.010,0.354]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWSC (z)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.051\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.064,0.166]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.085\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.026,0.196]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.053\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.094,0.200]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.183,0.191]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (SHD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.038\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.270,0.194]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.204\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.455,0.048]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e-0.019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.274,0.235]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e0.065\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.270,0.400]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.045\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.226,0.316]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.255,0.376]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.123\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.190,0.437]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e0.346*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[0.035,0.657]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTeaching experience (SHD, z)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.066\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.180,0.312]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.036\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.347,0.276]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.088\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.202,0.377]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e-0.229\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.504,0.046]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurrent role experience (SHD, z)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.226,0.086]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.054\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.221,0.113]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e-0.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.291,0.031]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e-0.083\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.318,0.152]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of Classes (z)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.084\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.110,0.278]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.036\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.204,0.277]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.073\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.133,0.279]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e0.142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.133,0.418]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of Students (z)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.028\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.141,0.198]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.057\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.143,0.257]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e-0.009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.204,0.186]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e-0.063\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.318,0.192]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchool type 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchool type 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.451,0.432]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.077\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.442,0.596]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.062\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.417,0.540]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e-0.111\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.676,0.455]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchool type 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.232\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.899,0.435]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.874,0.850]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e-0.131\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.974,0.713]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e-0.687\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-1.817,0.444]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"20\" nameend=\"c20\" namest=\"c1\"\u003e\u003cp\u003eCoefficients are school-level OLS estimates with HC3 robust SEs. SDH-HL (z)\u0026thinsp;=\u0026thinsp;standardized school-level health literacy on social determinants of health; WSC (z)\u0026thinsp;=\u0026thinsp;standardized workplace social capital. Reference\u0026thinsp;=\u0026thinsp;category reference for school type. p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003econtinued\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"20\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c20\" colnum=\"20\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eQuality of Delivery\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e\u003cp\u003eIntegration\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c15\" namest=\"c12\"\u003e\u003cp\u003eProgram Differentiation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c20\" namest=\"c17\"\u003e\u003cp\u003eAdaptation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003eβ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e95%CI\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConstant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.609***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[1.449,1.769]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.946***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[1.287,2.605]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.052***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e[1.911,2.194]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2.047***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[1.492,2.601]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e1.882***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e[1.710,2.053]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e1.737***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[1.027,2.446]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e2.005***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e[1.837,2.172]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e2.169***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[1.466,2.872]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSDH-\u003c/b\u003eHL (z)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.421***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e[0.282,0.560]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.465***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[0.273,0.657]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.214**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e[0.075,0.354]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.229**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[0.062,0.397]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u003cp\u003e0.270**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u003cp\u003e[0.080,0.459]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.270*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[0.041,0.498]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u003cp\u003e0.271**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u003cp\u003e[0.093,0.449]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e0.287**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[0.074,0.500]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWSC (z)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.063\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.101,0.227]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.083\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.077,0.244]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.099\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.071,0.269]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e0.038\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.149,0.224]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (SHD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.164\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.510,0.182]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.323,0.327]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.107\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.295,0.510]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.387,0.388]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.063\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.530,0.404]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.127\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.484,0.229]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e-0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.368,0.307]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e-0.054\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.424,0.316]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTeaching experience (SHD, z)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.192\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.283,0.668]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.212\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.096,0.520]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.242\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.063,0.547]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e0.181\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.171,0.532]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurrent role experience (SHD, z)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.091\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.287,0.104]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.069\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.307,0.169]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e-0.103\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.394,0.188]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e-0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.371,0.192]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of Classes (z)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.223\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.054,0.500]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.041\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.156,0.238]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e-0.061\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.404,0.281]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e0.146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.269,0.562]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of Students (z)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.045\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.223,0.313]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.137\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.065,0.339]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.270,0.278]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e0.044\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-0.242,0.330]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchool type 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003eref\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchool type 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.187\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-0.448,0.823]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.597,0.598]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e-0.166\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-0.845,0.514]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e-0.399\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-1.054,0.255]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSchool type 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.582\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e[-1.742,0.578]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.191\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e[-0.576,0.958]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c14\"\u003e\u003cp\u003e-0.055\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c15\"\u003e\u003cp\u003e[-1.290,1.181]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c17\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c18\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c19\"\u003e\u003cp\u003e-0.748\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c20\"\u003e\u003cp\u003e[-2.067,0.571]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"20\" nameend=\"c20\" namest=\"c1\"\u003e\u003cp\u003eCoefficients are school-level OLS estimates with HC3 robust SEs. SDH-HL (z)\u0026thinsp;=\u0026thinsp;standardized school-level health literacy on social determinants of health; WSC (z)\u0026thinsp;=\u0026thinsp;standardized workplace social capital. Reference\u0026thinsp;=\u0026thinsp;category reference for school type. p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated the construct and concurrent validity of the Japanese version of the Health‑Promoting School Implementation Questionnaire (J‑HPSIQ). The J-HPSIQ demonstrated a stable seven-factor structure with moderate-to-fair fit and high internal consistency (CR\u0026thinsp;\u0026gt;\u0026thinsp;0.80). Although the initial CFA reproduced the original seven-domain structure (Vennegoor et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), overall fit was only moderate; subsequent SEM that modeled Adherence as an outcome predicted by Dose, Participant Responsiveness, Quality of Delivery, and Integration yielded substantially improved fit. One notable exception was the Adherence\u0026ndash;Quality of Delivery pair, which exceeded the HTMT threshold and did not satisfy the Fornell\u0026ndash;Larcker criterion, suggesting partial conceptual overlap (Fornell \u0026amp; Larcker, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1981\u003c/span\u003e; Hair et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This pattern indicates that in Japanese schools procedural adherence and perceived delivery quality often coincide, as both may be regarded as indicators of professionalism and accountability. At the school level, higher SDH-HL among SHDs was positively associated with overall implementation and, in particular, with the domains of Quality of Delivery, Integration, and Adaptation, whereas associations with Adherence were small or nonsignificant.\u003c/p\u003e\u003cp\u003eThese findings are consistent with the European validation of the original HPSIQ (Vennegoor et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) and with research linking organizational health literacy to the quality and sustainability of implementation (Dadaczynski et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; S\u0026oslash;rensen et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). In Japan\u0026rsquo;s highly standardized school health system\u0026mdash;where compliance with policy mandates is embedded in administrative routines\u0026mdash;adherence functions largely as a baseline requirement rather than a marker of excellence (Japan School Health Association, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Tomokawa, Shirakawa, et al., 2021). SHDs occupy a pivotal role within this system: they coordinate health policy, facilitate staff collaboration, and liaise with external professionals such as school physicians and pharmacists (Japan School Health Association, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Their ability to interpret information and foster coordination helps determine how schools translate national standards into context-specific and collaborative practice. Consequently, variation in SHDs\u0026rsquo; SDH-HL may influence how effectively schools integrate health promotion into daily operations and respond to community needs.\u003c/p\u003e\u003cp\u003eThe modest discriminant validity between Adherence and Quality of Delivery may further reflect Japan\u0026rsquo;s administrative culture, in which procedural correctness and performance quality are closely intertwined. Within this framework, schools that demonstrate procedural thoroughness are also perceived as delivering high-quality practice, blurring the conceptual boundary between compliance and quality. Clarifying this distinction in future applications\u0026mdash;by emphasizing qualitative aspects of delivery such as participatory decision-making, staff engagement, and reflective evaluation\u0026mdash;could enhance interpretability without altering the instrument\u0026rsquo;s underlying structure.\u003c/p\u003e\u003cp\u003eThe J-HPSIQ retained the conceptual integrity of the original tool while revealing contextual nuances in how implementation domains interrelate. These nuances likely stem from Japan\u0026rsquo;s institutional configuration, where specialized roles (e.g., yogo teachers, school physicians, and pharmacists) and centralized governance define the structure of school health activities (Japan School Health Association, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Tomokawa, Miyake, et al., 2021). Yogo teachers manage daily health guidance and student monitoring, while external professionals provide mandated oversight and technical guidance (Tomokawa et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Tomokawa, Shirakawa, et al., 2021). This multilayered governance structure ensures procedural rigor and accountability but tends to limit bottom-up flexibility. As a result, schools in Japan exhibit Japan-specific patterns of coordination and adaptation\u0026mdash;characterized by hierarchical decision-making and role specialization\u0026mdash;compared with the more participatory approaches observed in decentralized education systems.\u003c/p\u003e\u003cp\u003eThe observed associations between SHDs\u0026rsquo; SDH-HL and the domains of Quality of Delivery, Integration, and Adaptation underscore the importance of organizational health literacy within leadership roles. Although causal inference cannot be drawn from this cross-sectional design, SHDs with stronger literacy regarding the social determinants of health may be better able to interpret contextual factors, mobilize collaboration, and align school initiatives with local priorities. Professional development programs that integrate social-determinants thinking into school management and teacher training could therefore strengthen schools\u0026rsquo; capacity for equitable and context-responsive implementation of the HPS framework (Jourdan et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Samdal \u0026amp; Rowling, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Policymakers may also employ the J-HPSIQ as a diagnostic tool to monitor implementation progress and to guide targeted capacity-building at prefectural or national levels.\u003c/p\u003e\u003cp\u003eThis study has several strengths, including the large, multi-occupational sample, rigorous translation and cultural adaptation process, and integration of both individual- and school-level covariates. The J-HPSIQ also demonstrated consistent reliability and theoretically coherent construct validity within the Japanese school context. However, several limitations should be acknowledged. First, the sample was limited to prefectural high and special-needs schools within a single prefecture. Although this yielded a relatively large and organizationally homogeneous dataset, the findings may not generalize to other regions or to different school types, particularly elementary and junior high schools where health promotion activities are often more systematically institutionalized. Broader validation across diverse educational settings is therefore recommended. Second, the cross-sectional design limits interpretation regarding temporal stability or predictive validity. Longitudinal or repeated-measure studies are needed to assess score stability over time and to evaluate the instrument\u0026rsquo;s utility for monitoring and guiding Health-Promoting School initiatives. Finally, all measures relied on self-report data, which may introduce social-desirability or common-method bias, although anonymity and multi-role participation likely mitigated this risk. Despite these limitations, the study provides a robust foundation for future longitudinal and multi-site validation of the J-HPSIQ.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe J-HPSIQ demonstrated satisfactory reliability and validity for assessing school-level implementation of the Health-Promoting School framework in Japan. The observed associations between SHDs\u0026rsquo; health literacy and key implementation domains highlight the relevance of organizational literacy for promoting effective, adaptive, and equity-oriented school health systems, while underscoring the value of capacity building within school leadership.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank all teachers who agreed to participate in this study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical approval\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of the Graduate School of Human Development and Environment, Kobe University (approval number 685-3; revision-685-3).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData availability\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe J-HPSIQ validated in this study will be considered for open release after further validation studies are completed. At this stage, the scale can be provided upon reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by Grants-in-Aid for Scientific Research (JSPSKAKENHI Grant Number JP24K00395) from the Japan Society for the Promotion of Science. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no other conflict of interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors contribution\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the concept or design of the study, the acquisition, analysis, or interpretation of data for the work. A.K. drafted the manuscript. K.M and M.T. critically revised the manuscript. All authors gave final approval and agreed to be accountable for all aspects of work, thus ensuring integrity and accuracy.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDeclaration of generative AI and AI-assisted technologies in the manuscript preparation process\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this work the authors used ChatGPT (OpenAI) in order to assist with language editing and improving clarity of expression. After using this tool, the author(s) reviewed and edited the content as needed and take full responsibility for the content of the published article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAnderson, J. C., \u0026amp; Gerbing, D. W. (1988). 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School Health Portal Site. https://www.gakkohoken.jp/books/archives/243\u003c/li\u003e\n\u003cli\u003eJourdan, D., Simar, C., Deasy, C., Carvalho, G. S., \u0026amp; McNamara, P. M. (2016). School health promotion and teacher professional identity. \u003cem\u003eHealth Education (Bradford, West Yorkshire, England)\u003c/em\u003e, \u003cem\u003e116\u003c/em\u003e(2), 106\u0026ndash;122.\u003c/li\u003e\n\u003cli\u003eKazemitabar, M., Moghadamzadeh, A., Habibi, M., Hakimzadeh, R., \u0026amp; Garcia, D. (2020). School health assessment tools: a systematic review of measurement in primary schools. \u003cem\u003ePeerJ\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e, e9459\u0026ndash;e9459.\u003c/li\u003e\n\u003cli\u003eKline, R. B. (2016). \u003cem\u003ePrinciples and practice of structural equation modeling, fourth edition\u003c/em\u003e (4th ed.). Guilford Publications.\u003c/li\u003e\n\u003cli\u003eKouvonen, A., Kivim\u0026auml;ki, M., Vahtera, J., Oksanen, T., Elovainio, M., Cox, T., Virtanen, M., Pentti, J., Cox, S. J., \u0026amp; Wilkinson, R. G. (2006). Psychometric evaluation of a short measure of social capital at work. \u003cem\u003eBMC Public Health\u003c/em\u003e, \u003cem\u003e6\u003c/em\u003e(1), 1\u0026ndash;10.\u003c/li\u003e\n\u003cli\u003eLangford, R., Bonell, C., Jones, H., Pouliou, T., Murphy, S., Waters, E., Komro, K., Gibbs, L., Magnus, D., \u0026amp; Campbell, R. (2015). The World Health Organization\u0026rsquo;s Health Promoting Schools framework: A Cochrane systematic review and meta-analysis. \u003cem\u003eBMC Public Health\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(1), 1\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003eLekamge, R. B., Jain, R., Sheen, J., Solanki, P., Zhou, Y., Romero, L., Barry, M. M., Chen, L., Karim, M. N., \u0026amp; Ilic, D. (2025). Systematic review and meta-analysis of the effectiveness of whole-school interventions promoting mental health and preventing risk behaviours in adolescence. \u003cem\u003eJournal of Youth and Adolescence\u003c/em\u003e. https://doi.org/10.1007/s10964-025-02135-6\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eMaking every school a health-promoting school \u0026ndash; Global standards and indicators\u003c/em\u003e. (2021, June 22). World Health Organization. https://www.who.int/publications/i/item/9789240025059\u003c/li\u003e\n\u003cli\u003eMatsumoto, M., \u0026amp; Nakayama, K. (2017). Development of the health literacy on social determinants of health questionnaire in Japanese adults. \u003cem\u003eBMC Public Health\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(1), 1\u0026ndash;11.\u003c/li\u003e\n\u003cli\u003eNorikoshi, K., Kobayashi, T., Tabuchi, K., \u0026amp; Oriyama, S. (2020). 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Multi-level, cross-sectional study of workplace social capital and smoking among Japanese employees. \u003cem\u003eBMC Public Health\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(1), 489.\u003c/li\u003e\n\u003cli\u003eTomokawa, S., Miyake, K., \u0026amp; Asakura, T. (2020). Sustainable human resource training system for promoting school health in Japan. \u003cem\u003ePediatrics International: Official Journal of the Japan Pediatric Society\u003c/em\u003e, \u003cem\u003e62\u003c/em\u003e(8), 891\u0026ndash;898.\u003c/li\u003e\n\u003cli\u003eTomokawa, S., Miyake, K., Takahashi, K., Tomokawa, A., Kokudo, S., Ueno, M., Kigawa, M., \u0026amp; Asakura, T. (2021). Health screening system to ensure the children\u0026rsquo; health and development in Japan. \u003cem\u003ePediatrics International: Official Journal of the Japan Pediatric Society\u003c/em\u003e, ed.14733-ped.14733.\u003c/li\u003e\n\u003cli\u003eTomokawa, S., Shirakawa, Y., Miyake, K., Ueno, M., Koiso, T., \u0026amp; Asakura, T. (2021). Lessons learned from health education in Japanese schools. \u003cem\u003ePediatrics International: Official Journal of the Japan Pediatric Society\u003c/em\u003e, \u003cem\u003e63\u003c/em\u003e(6), 619\u0026ndash;630.\u003c/li\u003e\n\u003cli\u003eVennegoor, G., Van Assema, P., Eekhout, I., Lezwijn, J., Molleman, G., \u0026amp; Jansen, M. (2023). Measuring Implementation of Health Promoting School (HPS) Programs: Development and Psychometric Evaluation of the HPS Implementation Questionnaire. \u003cem\u003eThe Journal of School Health\u003c/em\u003e, \u003cem\u003e93\u003c/em\u003e(6), 450\u0026ndash;463.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization and the UNESCO. (2021). Making every school a health-promoting school: implementation guidance. \u003cem\u003eThe Lancet Child and Adolescent Health\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(8), 539\u0026ndash;540.\u003c/li\u003e\n\u003cli\u003eWourld Health Organization. (2000). \u003cem\u003eLocal action: creating health promoting schools\u003c/em\u003e. https://www.who.int/publications/i/item/local-action-creating-health-promoting-schools\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"School health promotion, Implementation fidelity, Health literacy, Psychometric validation, Japan","lastPublishedDoi":"10.21203/rs.3.rs-7945462/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7945462/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eDespite the global spread of the Health-Promoting School (HPS) framework, few validated instruments assess the depth and quality of its implementation, particularly in non-Western contexts. The Health-Promoting School Implementation Questionnaire (HPSIQ), developed in the Netherlands, has demonstrated sound psychometric properties but has not been validated in Asia.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eThis study tested the factor structure and concurrent validity of the Japanese version of the HPS Implementation Questionnaire (J-HPSIQ) in relation to school health directors\u0026rsquo; (SHDs\u0026rsquo;) health literacy on social determinants of health (SDH-HL).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA web-based survey was conducted among 1,295 staff from 174 public high and special needs schools in Japan (2023). The seven-factor structure of the 28-item J-HPSIQ\u0026mdash;Adherence, Dose, Participant Responsiveness, Quality of Delivery, Integration, Program Differentiation, and Adaptation\u0026mdash;was tested using confirmatory factor analysis (CFA). Convergent and discriminant validity were examined through composite reliability (CR), average variance extracted (AVE), the Fornell\u0026ndash;Larcker criterion, and heterotrait\u0026ndash;monotrait (HTMT) ratios. To assess concurrent validity, multiple linear regressions examined associations between SHDs\u0026rsquo; SDH-HL and school-level implementation scores, adjusting for demographic and school-level covariates.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe initial CFA showed moderate-to-fair fit. A subsequent structural model specified Adherence as a dependent construct predicted by Dose, Participant Responsiveness, Quality of Delivery, and Integration. This model improved fit (χ\u003csup\u003e\u0026sup2;\u003c/sup\u003e(604)\u0026thinsp;=\u0026thinsp;1069.62, CFI\u0026thinsp;=\u0026thinsp;0.840, TLI\u0026thinsp;=\u0026thinsp;0.820, RMSEA\u0026thinsp;=\u0026thinsp;0.083; Δχ\u0026sup2;(15)\u0026thinsp;=\u0026thinsp;211.0, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). All factor loadings were significant (0.34\u0026ndash;0.87), with CR\u0026thinsp;\u0026gt;\u0026thinsp;0.80 and AVE\u0026thinsp;\u0026ge;\u0026thinsp;0.36. SHDs\u0026rsquo; SDH-HL was positively associated with total implementation (β\u0026thinsp;=\u0026thinsp;0.21, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), especially with Quality of Delivery (β\u0026thinsp;=\u0026thinsp;0.47, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Integration (β\u0026thinsp;=\u0026thinsp;0.23, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and Adaptation (β\u0026thinsp;=\u0026thinsp;0.29, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe J-HPSIQ is a psychometrically robust and contextually relevant tool for evaluating school health promotion in Japan. SHDs\u0026rsquo; health literacy was positively related to effective and adaptive HPS implementation, highlighting the importance of organizational literacy for equitable and sustainable school health systems.\u003c/p\u003e","manuscriptTitle":"Validity of the Japanese version of health promoting school implementation questionnaire","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-11 05:59:18","doi":"10.21203/rs.3.rs-7945462/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-05T10:06:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-22T17:38:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296021509682971390526555707626678844304","date":"2025-12-18T13:41:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-29T00:24:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"96983977395814216602446696622302258533","date":"2025-11-21T14:43:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-06T12:01:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-04T16:22:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-29T07:33:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-27T20:55:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-10-27T20:52:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2d3e9608-e3a2-4665-b7df-769b0106795f","owner":[],"postedDate":"November 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":57710426,"name":"Health sciences/Diseases"},{"id":57710427,"name":"Health sciences/Health care"},{"id":57710428,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-04-07T16:04:20+00:00","versionOfRecord":{"articleIdentity":"rs-7945462","link":"https://doi.org/10.1038/s41598-026-46477-y","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-04-05 15:59:13","publishedOnDateReadable":"April 5th, 2026"},"versionCreatedAt":"2025-11-11 05:59:18","video":"","vorDoi":"10.1038/s41598-026-46477-y","vorDoiUrl":"https://doi.org/10.1038/s41598-026-46477-y","workflowStages":[]},"version":"v1","identity":"rs-7945462","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7945462","identity":"rs-7945462","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}