Visualizing potential contextual influences in and across complex settings: a qualitative study on structured school health promotion implementation

Background Becoming a health-promoting school requires capacity to implement ongoing health promotion activities (HPA). Enhancing schools’ ability to manage change processes—e.g. through a plan-do-study-act (PDSA) cycle—has been identified as a promising capacity-building approach. However, contextual conditions at individual schools may influence the utilization of the PDSA cycle for HPA implementation. Understanding this influence is critical to determine whether tailored approaches are needed or whether the PDSA cycle can serve as a generalizable, effective strategy. This study aimed to investigate whether, which, and how contextual factors determine the application of the PDSA cycle for HPA implementation and to reflect on the methodological approach’s value for implementation research. Methods The study was part of an evaluation of a large-scale school health promotion program designed to build capacity through teaching the PDSA cycle. We combined qualitative interviews with representatives from nine schools with matrix heat mapping to visualize contextual factors influencing the perceived implementability of HPA using the PDSA cycle. Schools were compared to identify commonalities, differences, and determinant patterns. Results School representatives reported various contextual factors potentially influencing PDSA cycle utilization for future HPA implementation. Schools with prior experience using structured, PDSA-cycle-like processes perceived fewer contextual barriers and more facilitators, suggesting either the effectiveness of a structured approach or the necessity of certain contextual facilitators. Supportive communication structures, sufficient financial means, and space emerged as potential consequences of using structured processes or prerequisites for PDSA cycle use. Although lack of parental engagement, work infrastructure barriers, and time constraints were reported across nearly all schools, they did not inhibit some from applying structured processes. Conclusion Contextual factors shape the implementability of the PDSA cycle for HPA in schools. Whether these factors are prerequisites or can be shifted through applying the PDSA cycle remains unclear. Our study offers a methodological approach to examine implementation context in complex, multi-site settings. This approach may help identify determinant patterns and inform the broader debate on generalizability versus context-specificity in implementation research. Future studies should test this approach in larger, more diverse samples to guide strategy selection and inform scaling efforts.