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Table 3 Factors that influenced tool use, organized by ISF level and CFIR domains [14]

From: School health implementation tools: a mixed methods evaluation of factors influencing their use

CFIR construct Themes Exemplar quotations
Support system
 Outer setting
  Cosmopolitanism Interactions and partnerships with other organizations working to improve school health “I will say that’s probably our strongest asset we have in [state] is that our partners in all of those different groups, we know and we work and collaborate and communicate on a pretty regular basis.”
  External policy • Shift from No Child Left Behind to Every Student Succeeds Act
• CDC funding requirements and alignment with other federal agencies
• State standards/regulation
“The areas that have caused us setbacks would be unintended consequences of No Child Left Behind, in terms of a decrease in physical activity and within our schools. Hopefully now we’ll start seeing that uptick with ESSA and with physical education, health education being considered a well-rounded subject.”
 Characteristics of individuals
  Knowledge and self-efficacy • State staff had greater knowledge and self-efficacy for 2 tools. For somebody, like me, who has attended multiple trainings and oversees school health as an umbrella, I think it’s a little bit easier to grasp.
Delivery system
 Outer setting
  Student and family needs and resources Parent support for school health “Sometimes it’s the community or parent part of it. Cuz if you have parents that are really gung ho about making sure their kids are doin’ healthy lifestyles kind of stuff, then they can drive the administration.”
 Inner setting
  Culture of wellness A school’s health-related norms and values “I think some of it is culture within the school, but also within the community.”
  Relative priority How nutrition and physical activity were prioritized in relation to academics and other concerns “Whether it’s bullying or suicide prevention, or tobacco prevention, our guides around nutrition and physical activity are gonna be just one in a whole pool of guides.”
  Readiness for implementation • Leadership Engagement: Commitment and involvement of district and school leadership
• Resources: A paid district wellness coordinator.
• Access to knowledge and information. Teachers’ access to professional development related to the tools
“I see a principal as a gatekeeper and if that gatekeeper gets it, lots of these things are gonna be very impactful and effective.”
“…being able to have something that works and put programs in place, and then following up to really see the results that come out of that. That’s through those health and wellness coordinators.”
“If there isn’t a commitment to providing professional development, or dedicating dollars for training, or doing some sort of stipend for teachers, or covering for substitutes to get teachers trained… Then that policy’s not gonna go anywhere.”
 Characteristics of individuals
  Knowledge, beliefs and self-efficacy School staffs’ limited knowledge of CDC tools “…your teachers and staff who don’t know about them [CDC tools], don’t know how to use them, or don’t know how to access them.”
  Other personal attributes School staffs’ motivation, particularly champions “I think there’s a lot of intrinsic motivation that’s going on with the people who are champions within our region. I think it just takes a certain element of resiliency…”