Inductive content analysis revealed many themes, here called conditions, that were divided into two categories: ‘core conditions’ which were conditions necessary for CSH to be successfully implemented and were thus at the ‘core’ and ‘contextual conditions’ which were not as essential but had a great degree of influence on the ability for the core conditions to be obtained. Themes for both core and contextual conditions are described in more detail below. As well, while not described as themes, it was the ‘process conditions’ (1. assess, vision and prioritize; 2. develop and implement an action plan; and 3. monitor, evaluate and celebrate) developed as part of APPLE Schools best practice that allowed for the ‘core’ and the ‘contextual conditions’ to be mobilized in practice to facilitate CSH implementation. Collectively, these ‘process conditions’ previously established by APPLE Schools and the presently described ‘core’ and ‘contextual conditions’ represent the essential conditions for successful implementation of CSH (illustrated in Fig. 1).
Core conditions
Factors identified within this theme were emphasized as core conditions for CSH implementation across all stakeholders. In other words, without these conditions, participants felt CSH could not be successfully implemented. These conditions included: students as change agents; school-specific autonomy; demonstrated administrative leadership; dedicated champion to engage school staff; community support; evidence; and professional development.
Students as change agents
All stakeholders believed that students were the heart of the project and were the reason for wanting to implement CSH. As one teacher noted: “…I think we look at it as we want our students to do better academically, socially, emotionally and everything that the APPLE School project does supports that.” (DS3). Participants also reported that students who were enthusiastic and energized by the project were more likely to accept and engage within the project, and to communicate the CSH message beyond the school walls, propelling the project forward. As outlined by one SHF: “[You are] not going to do a whole bunch of stuff in the school to try to affect kids’ health if kids don’t like what you’re doing. That’s just a reality of it.” (DS2).
Notably, students were seen as the drivers of change in the home environment. While parental support was seen as a facilitator of CSH implementation, it was often difficult to engage the parent group. Stakeholders suggested that a potential means of engaging parents was through the buy-in of the children. As stated by one SHF: “I’m hoping that through the students that they’ll get the parents…And then obviously those parents that are more involved…can model it for the kids themselves.” (DS2). As a result, most stakeholder groups felt that initially it was best to ensure parents were aware of the changes, but to continue focusing on the children. Once engaged, parents were reported to communicate the CSH message more broadly, helping to reinforce the cultural shift. One principal summarized this phenomenon: “…if the parents are on board…they can be great advocates for the things that we [want to] change in the bigger community because they do the parking lot talk….” (DS4). In sum, while the engagement of both students and their families should remain a priority, participants felt that students played a much bigger role in influencing the home environment and therefore prioritized their involvement in the project.
School-specific autonomy
A core condition identified by stakeholders was the autonomy of each school, which required customization of the intervention to meet local needs. Autonomy was seen as imperative to build a sense of ownership for each school community. The intervention needed to be flexible to allow each school to build upon their strengths, assets and needs. As one teacher indicated: “Not every school is going to have the same way of doing things [or have] the same issues and needs…so if you can be flexible enough and respond to the things that are happening in the school, you’re in. I think the project is more beneficial that way.” (DS3). Participants felt that the process conditions as well as their ability to use school-specific evidence from evaluation reports were the drivers of this core condition. Action plans were developed through consultation with students, parents, teachers, school staff, and principals, as well as through the creation of an APPLE Core or Wellness Committee within the school which included community representation. Evidence provided through evaluation also allowed each school to customize the intervention based on data-driven decisions unique to their school community. One incredible success story is illustrated by an administrator who noted: “47 % of our families reported that they were worried that food would run out before more money would come in. As a result, policy was changed immediately and all field trips and hot lunches became free.” (DS5). It should be noted that securing funding is often quite difficult, but in this case the local community responded to such powerful evidence.
Demonstrated administrative leadership
All stakeholders strongly emphasized the importance of demonstrated leadership for successful CSH implementation, particularly the role of the school principal. This finding was perhaps the strongest result to emerge from the secondary analysis. Demonstrated administrative leadership differed from passive buy-in from the principal in that the principal was seen to play an invaluable role throughout the process of implementing CSH, and a key stakeholder in truly being able to facilitate a culture shift within a school community. The principal was seen as an active member of the implementation team and not purely a strong supporter of other champions such as the SHF. Teachers indicated that active leadership by the school principal allowed for CSH to become an essential component of the school’s agenda and thus was an identified priority area, as emphasized by one teacher: “…I think if you’re in a school that didn't have an administrator who felt that healthy, a healthy lifestyle was important the program wouldn’t be what it is.” (DS3). SHFs also emphasized the vital role that the school principal played as being a powerful influence for what practices are adopted and maintained within the school. As quoted by one SHF: “I think the principal is probably the most important. Because anything that goes on has to go through him and if he’s not supportive, then it’s not going to happen.” (DS2). One principal summarized their role by stating: “…it’s a huge role because you really set the vision…everybody is watching you for the leadership so you have to choose carefully the direction that you want to head.” (DS5). Principals were seen as key advocates and role models for CSH, as one administrator mentioned: “I truly believe that I have to walk the talk…Kids won’t listen to what we say, they’ll listen to what they see us doing” (DS4).
Dedicated champion to engage school staff
While the role of the administrator was seen as imperative from a leadership perspective, participants also indicated that having a SHF, or school health champion, was imperative to get the project up and running. Teachers, in particular, viewed the role of the SHF as a catalyst for the ongoing integration of the CSH model into daily practices, and this presence kept them focused on the project. Principals felt that without the champion, the project would not have been initiated due to the busy nature of the school environment. Although an important factor, the SHF was also mentioned as a barrier by some, particularly within the latter stages of implementation. As implementation proceeded, others in the school may have become apathetic in picking up the tasks of the SHF, limiting the sustainability of the project. One principal spoke to this problem in the following quote: “… when you designate somebody to have a particular job in one area…you celebrate the fact that you’ve got somebody in charge that’s going to spearhead that. But you risk losing everybody else because they now say ‘but she’s getting paid to do that organization’s stuff. So why should I take that on and volunteer my extra hours…?’” (DS4).
It was reported by participants that in order to truly shift a school culture, all members of the school community needed to play a role. SHFs identified that learning to go from ‘doing’ to ‘facilitating’ in the school was essential for sustainability of successful changes in the school culture. SHFs reported that all school staff, and notably teachers were seen as a core component of CSH implementation in that they are the ones who are actively integrating CSH into practice at a ground-level. The need for school staff buy-in was also supported by the principal: “…it has got to filter down to the individual classroom teacher, to the secretary, to the custodians, to the educational assistants – they’re the ones who are, you know, in the trenches and they’re having to actually implement these things.” (DS5). SHFs echoed this sentiment, by alluding to the role of a teacher as not only an advocate, but also a gatekeeper of the project, with one SHF stating: “You need buy-in from the teachers… if your teachers don’t believe in it, then they’re not going to promote it within their classrooms, even though their administrator has an expectation of them.” (DS1). While the role of the teacher actively advocating for CSH took time to evolve and was not as prominent during the initial stages of implementation, their role flourished over time as implementation proceeded and as the project became one that was led by distributed leadership.
Community support
All stakeholders mentioned the key role that both internal and external partnerships played in alleviating the pressures of implementation and essentially created a ‘village’ of those supporting CSH. Participants indicated that the internal relationships formed between school staff, SHFs, administrators and other project staff was invaluable to share lessons shared. As one SHF stated in regards to support from other SHFs: “I think if you didn’t have that, you could feel so isolated.” (DS1). When examining external supports, one principal asserted: “I don’t think you can do it by yourself. There are too many needs at these schools and so you have to be able to bring in outside partnerships.” (DS4). SHF also appreciated knowing that there were external resources to support their work.
While participants stressed that the majority of their time during the initial stages of implementation needed to be spent engaging those internal to the school community, they did indicate that having strong community connections strengthened the type of programs the schools could offer and enhanced the social environment. As stated by one SHF: “Cooperation. And relationships for sure. Starting within the school and then getting community. Definitely, like – I think unless you have the cooperation from everyone involved in the school community, I mean then it’s going to be a struggle.” (DS2). Because stakeholders felt it was important to spend time building relationships with internal stakeholders during the initial implementation of CSH, it was seen to be beneficial to begin establishing connections with external community partners and services prior to implementation.
Evidence
The ability to use local school-level data (both process and outcome) was seen as essential for planning, refining, and supporting the implementation of CSH. This was in the form of both research findings relating to health behaviours and environmental-level changes, as well as more informal evaluations. In regards to planning, stakeholders indicated that the research evidence in the form of individualized school reports allowed them to make decisions based on their school context. These reports include information on students’ physical activity, nutrition, screen time, sleep habits, BMI, as well as their home and school environments. These reports are provided by the University of Alberta’s School of Public Health following annual data collection. One principal compared the use of their local data to the use of standardized test results: “We analyze the data, we say – it’s like our provincial achievement test results. What’s the data telling us? How is that going to inform our planning for next year?” (DS5).
In addition to planning, stakeholders indicated data were also useful to support the intervention and increased buy-in from the school community, including parents, staff, and the school district. As indicated by one SHF: “…when I meet with parents and staff here and there, they’re like, ‘Well do you have evidence? Do you have proof?’, ‘Do you have proof that it helps kids behave better, stay focused in class?’ Yeah. I do…cause then you’re going to get so much more buy-in.” (DS2). As well, one principal stated: “the information is shared with staff and it goes into our priorities for why we need to continue…and certainly the information is shared with my school council.” (DS5). As well, the evidence allowed each school community to not only celebrate their successes but also to adapt the intervention on the basis of findings.
Professional development
Stakeholders believed that both initial and ongoing professional development were paramount in informing school members of the project goals, objectives, and rationale , and built self-efficacy for project implementation. SHFs specifically stated that the training strengthened their knowledge and essential skills for working in the schools and built not only their competence but also their confidence in implementing CSH. As quoted by one: “I think we have to have meaningful professional development for us as facilitators and also for staff.” (DS1). As well, another SHF stated “Seeing practical examples in action was essential to prepare me for the work.” (DS1). Teachers appreciated the resources and professional development provided through staff meetings, the SHFs and other professionals, allowing project material to become infused into the classroom. This in turn increased teacher ownership and support for the project. One teacher commented regarding the training and education provided by the SHF: “…she’s teaching your kids but she’s also teaching you, so then you’re going to have that knowledge and then carry it forward when she’s not here.” (DS3). As well, principals indicated that without the professional development prior to and throughout implementation they would not have had a clear understanding of the project, which they felt was necessary to ensure the project values and their values were aligned prior to implementation.
Contextual conditions
Contextual conditions were cited to have a great degree of influence on the ability for the core conditions, mentioned above, to be obtained. As such, they acted as important considerations for successful CSH implementation and included: time; funding and project supports; and readiness and prior community connectivity.
Time
All stakeholders emphasized the role that time plays within the implementation process. Enough time was needed to be dedicated to the project in order for it to be successful. This was often difficult within a busy school environment where multiple priorities and competing interests often interfered with project objectives. As one principal indicated: “…the challenge is that the central purpose of the school is teaching and learning and working towards building students’ achievement. And there is only a certain amount of time built into the school calendar. And realistically, that’s what teachers have to focus on.” (DS4). Time was also cited as essential in order to prevent CSH from being viewed as an add-on, but rather as an embedded part of the school’s culture. As suggested by one SHF: “So being able to give time to people to dedicate to health promoting schools and not just have it be their passion that they do on the side. I think that’s pretty essential.” (DS2). Principals also emphasized that allotted time allowed for implementation to become more impactful. As stated by one principal: “You can get all the money in the world but if you don’t get an extra two hours a day to implement, you’re not going to you know, impact something.” (DS5).
Funding and project supports
Stakeholders asserted that the financial support from the project greatly facilitated implementation. As stated by one principal: “The financial support from the project was huge…it’s not about questioning whether the healthy initiatives are important. It’s about our primary role is to be teachers and leaders of education…” (DS4). Stakeholders recognized that school budgets were tight, requiring external resources to support CSH objectives that lay outside of traditional school priorities. This sentiment was relayed by another principal: “School resources are strained. Certainly it’s difficult to justify taking educational dollars away from student to learn and putting that towards a lunch program.”(DS5). The structure and managerial supports provided through the CSH projects also facilitated implementation. This included support from CSH team managers and project staff who were actively involved in ensuring schools were accountable and had the help and guidance they needed during implementation, including grant writing to secure sustainable funding after initial implementation.
Readiness and prior community connectivity
It was important for stakeholders to have an understanding for CSH and the reason for its existence as this knowledge helped to build competency and increased ownership and enthusiasm over the project. For example, once teachers were able to develop a clear understanding of the project’s objectives, implementation was viewed as “natural” and healthy eating and active living activities were “easily incorporated.” It was also important for stakeholders to feel comfortable within their school, with foundational knowledge of the context and resources as well as established relationships in the school. As expressed by one principal: “…I think the biggest challenge, again, for me, was I don’t think an APPLE school should go into a place where the principal is brand new… when you come in new like that, it takes you six months…as the principal…to figure out your people.” (DS4). SHFs new to a school found that they spent a great deal of time in the beginning building trusting relationships with others. This was expressed by one SHF who shared: “I think the biggest thing is you have to, you know, develop that relationship. You have to meet everyone, let them know who you are…” (DS1).