Understanding context in the implementation of school health promotion: a scoping review and conceptual framework.

Abstract

Background: Schools offer an influential setting for delivering health promotion interventions. However, the success of these efforts largely depends on how well the implementation context is understood and addressed. While "context" is recognized as a key concept in implementation science, it remains inconsistently defined and applied. Therefore, the aim of this scoping review was to critically examine theoretical approaches used in implementation of school health intervention programs, and to explore how these approaches conceptualize and address context. Ultimately, the goal is to develop a conceptual framework that can support researchers, practitioners, and decision-makers in better understanding and addressing context in school health promotion.

Method: This scoping review was conducted following the Joanna Briggs Institute (JBI) guidelines. A search was conducted in Medline and ASSIA on June 18th, 2024. Articles were screened independently by two authors. After data extraction, a reflexive thematic analysis approach was used to analyze data.

Results: Our findings reveal that various theoretical approaches including implementation, adaptation, and system frameworks, as well as organizational and actor-network theory, have been utilized to conceptualize and address context in school health promotion. These approaches were applied across different stages of implementation: planning, delivery, and evaluation. However, our results confirm considerable variation in how these theoretical approaches address and define context. These different ways of defining context not only highlight a lack of consensus around its definition but also have significant implications leading to the prioritization of certain aspects of context over others, resulting in a fragmented, incomplete understanding of the social, cultural, economic, and political setting within which interventions are implemented. Using reflexive thematic analysis, we identified two overarching themes. The first theme, dimensions of context, comprises four contextual dimensions: organizational, socio-cultural, economic, and political. The second theme, features of context, captures the dynamic, interconnected, non-linear nature of context, and its spatial and temporal aspects. Together, these dimensions and features are integrated into a visual framework, the Contextual Framework for School Implementation (CFSI). The framework is further supported by practical guiding questions spanning all implementation phases: planning, delivery, and evaluation, emphasizing the importance of considering implementation context from the outset of program development.

Conclusions: This review examined how theoretical approaches have been used to understand and address context in school health promotion. It shows that while context is often recognized as important, current ways of describing and applying it are fragmented and incomplete. By integrating the key dimensions and features of context, the proposed framework provides phase-specific questions to guide planning, delivery, and evaluation for understanding how context shapes implementation. The framework may also help explain certain implementation challenges, supporting both researchers and health practitioners in navigating contextual complexity throughout the implementation process, thereby informing context-sensitive health policy and practice.

Systematic review registration: This study was based on a registered protocol ( https://osf.io/azdv4/ ). It is part of the Changemaker project funded by the European Union (GA No 101137359).