Visualizing contextual determinants in and across heterogeneous settings: a qualitative study on structured school...

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.

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.

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.

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.