From leadership research to district action: Visualizing contextual determinants in and across heterogeneous settings: a qualitative study on structured school health promotion implementation

AI-assisted editorial implementation guide. Proposed district actions are separate from the original authors’ findings and recommendations. Independent peer review of this guide is not asserted.

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Evidence and transfer

Education-related source: verify which participants, institutions and outcomes were actually studied before district adoption. Source publication type: research-article. License and identity checks do not establish study quality or causality.

Original authors’ abstract, reproduced under the source license:

Background Schools have the potential to promote equitable health from early life onwards yet require sufficient organizational capacity to achieve sustained action. Structured improvement approaches, such as PDSA cycles, may help strengthen this capacity by guiding systematic implementation processes. However, their potential in school health promotion remains insufficiently understood, particularly regarding the heterogeneous contextual factors shaping their application. This study examined which contextual determinants shape schools’ perceived implementability of the PDSA cycle for health promotion and how these conditions differ across schools. Methods Nine German primary schools participating in a holistic health promotion program were purposively sampled to capture heterogeneity across federal states, socioeconomic contexts, and urban–rural settings. Semi-structured qualitative group interviews in a workshop format were conducted with school principals, teachers, and parents and analyzed using the framework method guided by the CFIR. To facilitate cross-case comparison, color-coded valence ratings (facilitator/barrier/mixed) were visualized in a Matrix Heat Map, enabling identification of contextual tendencies. Results Fifteen contextual factors emerged across the CFIR domains of Outer Setting, Inner Setting, and Individual. Schools with prior experience using structured processes similar to PDSA cycles reported more facilitators, such as established communication structures, while schools without such experience perceived more barriers, notably financial constraints. Common barriers across schools included limited parental engagement and staff shortages, whereas leadership support and compatibility of program components were consistent facilitators. Some factors interacted dynamically, with resource constraints reinforcing other barriers or with strong mission alignment amplifying engagement. Conclusion Schools’ prior structured experience seemed to be associated with how they perceived the implementability of PDSA cycles for health promotion implementation, with more experienced schools anticipating more facilitators and fewer barriers. While causality cannot be inferred, these exploratory findings are hypothesis-generating and suggest that prior structured experience may be an important factor to consider for tailoring implementation support and building organizational capacity. Beyond these insights, extending the framework method with a color-coded Matrix Heat Map proved valuable for visualizing contextual heterogeneity and revealing tendencies across cases. This combined approach may inspire further research on how contextual configurations shape the use of structured processes in complex, multi-site implementation settings. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-026-00861-x.

Study methods

Data for this study were collected in December 2023 and January 2024 as part of the implementation evaluation of a holistic school health promotion program in German primary schools (three cohorts with 300 schools each). Schools from all over Germany were recruited via email, following a detailed sampling strategy to achieve maximum heterogeneity and include at least 25% of schools from socio-economically disadvantaged areas [35] (Additional File 1). The program encompasses individual-level and organizational-level HPA as well as capacity-building components. An example of individual HPA is the provision of teaching materials on nutrition to be used by the teachers in class. An example of an organizational HPA is the provision of equipment for physical activity to be handed out to the pupils. However, capacity-building is the program’s primary focus. Schools are trained to apply a structured PDSA cycle for their HPA (that they select), now and in the future. At the start of the program, a so-called steering group has to be established at each school, involving the principal, two teachers and a parent representative. Their task is to lead the implementation and change process. Throughout this process, schools are supported through implementation strategies such as trainings, counseling with individual contact persons, get-together meetings, and materials. After two years, the aim is that schools are able to conduct HPA on their own following the PDSA cycle in a structured way. All participating schools are offered the same program content and implementation support, regardless of individual school context. Ethics approval was obtained for all data collection procedures of this evaluation project from the ethical committee of the Technical University of Munich (2023–12-NM-KH).

Limitations

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A 90-day district inquiry

Days 1–15 · Appraise. Read the source methods, recruitment, comparator, outcomes and limitations. Record how the study setting differs from your district and which claim the design can support.
Days 16–30 · Design. Choose one school improvement question with teachers. Protect a short shared planning cycle, agree an instructional change and use a common rubric for examining student work. Agree participation, privacy protections, baseline and stopping rules before starting.
Days 31–60 · Observe. Collect the pre-agreed measures, keep a log of implementation changes and invite confidential voluntary feedback. Preserve existing support for staff and learners.
Days 61–90 · Decide. Review implementation fidelity, teacher time and independently scored student work against a recorded baseline. Examine access differences and competing explanations before attributing changes to leadership. Make a dated decision to stop, revise or extend the inquiry.

Board decision brief

Present the local problem, source setting, evidence limits, intervention, responsible owner, total cost, measured changes and uncertainty. Separate staff perceptions, implementation measures and student learning outcomes.

Attribution and reuse

Katharina Sterr; Deborah Cragun; Filip Mess; Friederike Butscher; Monika Singer; Simon Blaschke. Visualizing contextual determinants in and across heterogeneous settings: a qualitative study on structured school health promotion implementation. Implementation Science Communications (2026-01-16). https://doi.org/10.1186/s43058-026-00861-x

Prepared 2026-11-07. Source authorship and DOI are preserved. The abstract and source passages are attributed extracts; this editorial guide is offered under the same CC BY 4.0 license.