There is strong evidence for the many benefits of children engaging in physical activity (PA) and developing healthy eating habits, including reduced risks of depression, anxiety, cancer, type 2 diabetes, obesity, and cardiovascular disease (1–3). However, most American youth do not meet PA recommendations, and most school-aged students do not consume enough fruits and vegetables to meet the dietary guidelines (4–6). The discrepancy between PA and healthy eating recommendations and the reality of children's lack of engagement in these behaviors supports the ongoing need for interventions that promote behavior change. Schools are an important setting for promoting health, given their ability to reach many children, regardless of ethnicity, background, or gender. They also provide an opportunity for continuous, intensive interventions over long periods of time (7, 8). Children spend a large proportion of their time in schools—over 6 h per day for nearly 180 days per year (7–9). Additionally, school programs have demonstrated effectiveness in increasing PA (10, 11), positively affecting the consumption of vegetables, fruits, sugar sweetened drinks, and fast food (12–14) and promoting positive youth development among youth (15). However, when developing a novel program for the school setting it is important to understand potential program specific barriers that may promote or impede delivery (e.g., adoption, implementation, sustainment) (16–18).

School-based PA, healthy eating, and positive youth development programs face critical challenges to implementation (19). Several reviews found that some of the most prevalent barriers to program implementation include staff beliefs that conflict with the program's aim (e.g., underlying value of the intervention or program), lack of access to necessary resources, lack of access to necessary resources, supportive leadership, staff buy-in, and understanding of the program's principles and purpose, as well as other specific school characteristics (e.g., school size, high school vs. elementary school) (20, 21). Another study that examined school-based interventions found that ‘inner contextual factors' (i.e., factors within the school) were predominately related to sustainability, including availability of facilities or equipment, continued executive or leadership support, and implementation team cohesion (22). Furthermore, these results are supported by numerous other studies that identify additional barriers to various aspects of implementing school-based interventions, including managing students, inadequate resources, and a lack of time, knowledge, skills, competence, and training (22–24). Conversely, access to resources to support implementation, presence of effective and supportive leadership, access to ongoing training, effective communication about the purpose and outcomes of the program, teacher support, good training, and technical assistance can all facilitate the delivery of school-based programs (20, 22, 25).

Strong Teens for Healthy Schools (STHS) is a middle school program that was adapted from an adult civic engagement and health behavior program, the Change Club, which was created to empower people to take an active role in creating healthier eating and PA environments in their community (26). The STHS curriculum, which uses the theory of planned behavior (27–29), the socioecological model (30–32), and the whole school, whole community, whole child (WSCC) model (33, 34) to address PA, healthy eating habits, and positive youth development, is comprised of 16 one hour sessions, with half devoted to civic engagement skills and half alternating between PA and nutrition topics. One novel component of the curriculum is the student-led project to promote healthy environments within schools. Creating a health-focused change to the built environment through civic engagement is an evidence-based method that has been implemented in both rural and urban communities (35–38). These programs have demonstrated success in facilitating environmental change (39, 40) and have been integrated successfully into evidence-based, multilevel interventions as well (38). STHS adapts its civic engagement curriculum from these prior iterations to target adolescent cardiometabolic health in the school environment. STHS is also aligned with the Texas Essential Knowledge and Skills (TEKS) (41)—curriculum standards set by the state board of education—to help improve adoption of the program in Texas schools.

Achieving behavioral changes and promoting health benefits in educational settings requires a comprehensive understanding of factors that may impede or support the delivery of effective programs within school settings (22). Given the novelty of this approach in a school setting, understanding potential barriers and facilitators to its implementation in schools is essential to informing the development of implementation strategies that can enhance the delivery and sustainment of programs over time (22, 42). The Consolidated Framework for Implementation Research (CFIR) (43) is a conceptual model that divides the implementation of a given program into five domains (Figure 1)—the innovation (i.e., the program being implemented); the individuals involved with delivering the innovation, including implementers, leadership, support staff, administrators, recipients, etc.; the inner setting where the innovation is implemented; the outer setting, which includes the surrounding community and context beyond of the inner setting; and the process (i.e., how implementation occurs). Given the complex, multi-level nature of STHS, CFIR provides the most comprehensive understanding of factors that may affect program delivery throughout all phases of implementation (adoption, implementation, and sustainment), whereas many other models are more limited in their focus. Additionally, CFIR has been previously used to help identify and categorize barriers and facilitators to the implementation of other programs in the school setting (44–47) and has successfully helped to generate implementation of other programs and generate implementation strategies that aim to improve program delivery (48).

Overall, school-based interventions to promote health face a number of implementation challenges that can adversely impact the outcomes of such programs (20, 22, 24), but frameworks such as CFIR allow implementers to anticipate and adapt their interventions to overcome barriers (44, 45). However, STHS uses a novel civic engagement approach to school-based health and poses challenges to implementation in the school setting. Therefore, this study investigated the perceived barriers and facilitators to implementing STHS from the perspective of Texas Cooperative Extension staff (i.e., health educators) and middle school staff before it was delivered in schools to inform program delivery.

Extension staff (n = 20) and school staff members (n = 15) completed qualitative interviews between March of 2023 and March of 2024. Most participants were female, non-Hispanic White, with 6 or more years of experience in their respective roles (Table 1). The average age of participants was 41 years old (standard deviation ± 9.2 years). The interviews lasted an average of 33 min (rounded to nearest minute), with a standard deviation of ±11 min. The shortest interview was 16 min, and the longest interview was 59 min.

Although STHS is designed to be deliverable either by school staff members or by extension agents, participants emphasized the necessity of training the implementer on the program components, particularly its most critical components, to ensure fidelity. These comments were often made in reference to implementer time constraints and their need for clear expectations about their role (Table 2, Quote 1); implementers balancing multiple demands on their time may inadvertently skip important pieces of the curriculum if they are not emphasized in training. Aside from training, however, participants noted that the curriculum itself was appealing in that it would require very little expert knowledge or preparation time, thereby promoting its consistent use by implementers (Table 2, Quote 2).

In regard to fitting STHS into the school's programming, participants noted that although after school programs can be beneficial for students, after-school programs lacked consistency in terms of delivery (e.g., student might not attend every day) and educational standards (e.g., after school programs may not align with the same educational standards required in the classroom) that participants believed would be necessary to successfully implement STHS (Table 2, Quote 3). According to the participants, implementing STHS inside a classroom setting, such as an elective or part of physical education or health courses, would be more suitable for consistency of delivery.

For the implementers of the program, interview participants generally affirmed that the STHS curriculum itself was easy to understand and could be adequately delivered by teachers of any experience level. Some participants noted that the educator's level of experience, however, could influence delivery in subtle ways that, while not hindering adequate delivery, might result in varied experiences and engagement. Veteran teachers may be better equipped through training and experience to manage the pace of the sessions to fit allotted times, where novice teachers may struggle with ensuring all content was covered in the same amount of time. Participants also mentioned that in classes with shorter sessions, experienced teachers would know how to add supplemental material to fill out the time, whereas new teachers may be left with gaps in their schedule (Table 3, Quote 1). It was also noted that Extension staff may struggle with the timing more than schoolteachers, as their experiences with program delivery do not always involve middle-school education settings, and thus they may need more guidance on classroom management (Table 3, Quote 2).

Participants viewed STHS as a source of critical information and skills for middle-school students. Specifically, the connection between nutrition, PA, and mental health, particularly during this critical developmental age, was a topic from which participants thought many students would benefit (Table 3, Quote 3). Participants also discussed the civic engagement components of STHS as a needed skill for this age group, asserting that such material could be helpful in identity formation for middle school students as they progress through adolescence. On the other hand, aspects of the developmental stage of these years could create an added challenge for engaging middle school students in the curriculum. For example, the wide range of maturity levels among potential students could make it difficult to present the material or expect students to engage appropriately (Table 3, Quote 4).

Structural characteristics regarding the layout and facilities of the school were mentioned primarily by school staff participants as being important for the implementation of STHS. In most cases, school staff had no concerns about accommodating the program's physical activities. In some cases, however, implementers who described their school settings as smaller and/or in rural areas, noted that interior space was often multi-purpose, such as gyms combined with cafeterias, which might limit their ability to use those spaces. However, these schools often had abundant outdoors space, which participants noted as a possibility for supplementing the program's space requirements (Table 4, Quote 1).

In addition, the use of classroom lessons and physical activities was seen as an effective, but logistically tricky, combination. For example, although nearly all schools had adequate physical education space, such as a gym, participants discussed how moving between the gym and the classroom during the instructional period may be cumbersome to the implementers. On the other hand, if the program were implemented in a gym by default, additional considerations or planning would be needed to make sure the gym was equipped with the necessary items to facilitate the curriculum's classroom lesson (e.g., desks, screens) that are not typically a part of the physical education space (Table 4, Quote 2).

Participants suggested that STHS would only be feasible to implement if it did not create any new demands for the school staff. For many participants, this was emphasized in the fact that they saw STHS alignment with the TEKS as a benefit of the curriculum. Class time in almost all subjects must be dedicated to meeting the TEKS standards, which are evaluated in statewide standardized testing. Thus, STHS aligned with the requirements and processes already in place in the schools and would not be perceived as taking anything away or adding additional burden to staff (Table 5, Quote 1). It is worth noting that alignment with TEKS was seen as a facilitator to implementation, but several Extension staff members expressed that it was not a guarantee of program adoption by the school due to difficulty implementing any kind of program in schools during state-mandated testing season.

Participants voiced a nearly unanimous positive reception to the design of the STHS curriculum in terms of its usability (e.g., clear, simple instructions) and thoroughness (e.g., self-contained, all materials provided). In addition, participants thought that the variety of activities and lesson structures would appeal to all types of students and a variety of learning styles. The curriculum was also praised for its minimization of “sit and get” learning, described as students simply sitting and listening to traditional, formal lectures (Table 5, Quote 2). Instead, participants discussed how STHS favored group-based activities, active learning, and physical engagement. The balance of activities was also considered a high point, in that no single learning style or teaching format (e.g., group vs. individual tasks, video vs. reading) stood out above the rest (Table 5, Quote 3).

STHS was also discussed in reference to other programs (or the lack thereof) that addressed similar topics. The nutrition and/or PA information covered by STHS was considered to be specific and actionable by participants, whereas the lessons in comparable programs were often too vague or generalized to be particularly useful to students (Table 5, Quote 4). Furthermore, participants asserted that STHS was overall more comprehensive in its approach, covering a variety of topics relating to nutrition, as well as connecting them to health and social connections in a way that is not typically done within school-based curricula (Table 5, Quote 5).

In reference to the context in which the school operates, a frequent topic of discussion by Extension staff was the Student Health Advisory Councils (SHACs), which are required by Texas law to be established in each school district and are required to meet at least four times per year. Texas SHACs are comprised of educators and administrators, county extension agents, and local residents. Interview participants cited the SHAC as a logical partner in adopting and delivering the STHS program into schools (Table 6, Quote 1), though some noted that SHACs can be inconsistently administered, understaffed, or overburdened with existing obligations. Comments regarding SHACs—both positive and cautionary—came from Extension staff, consistent with their role as health and education promotion agents within the county who regularly partner with community advisory and steering committees such as SHACs.

The mandate of the SHAC is to ensure that school district health priorities reflect the priorities and values of community residents. In this regard, participants noted that in their preparation for the academic year, local priorities are given precedence, meaning that programs such as STHS must align with not only the implementer's objectives, but the goals of stakeholders in the broader context as well (Table 6, Quote 2). The implementation challenge for STHS, then, would be in the assumption that SHACs would be a consistent source of support between years. Finally, participants noted that factors outside of their influence or control, such as staff turnover at the district or school administrator level (Table 6, Quote 3), could impede implementation of programs like STHS.

Implementation of evidence-based innovations requires identification of barriers and facilitators to using that program with a specific population in a specific setting. To this end, the CFIR framework was preemptively applied to interviews conducted with Texas middle-school educators and extension staff regarding the STHS program at their respective school(s). The study found that participants provided generally positive comments, with some specific caveats and hesitations, about the potential for implementation of STHS. These findings align with much of the literature on barriers and facilitators to school-based programs; programs are more likely to be successfully implemented when there is support and training available from the program developers²⁵, which the participants noted as a positive strategy to promote buy-in from school staff and leadership.

Additionally, aligning programs with state-mandated testing requirements, which several participants mentioned as a strength of STHS, reduces the competition in school priorities, a documented barrier to implementation (25). Based on these findings, it will be important for researchers, and eventually, Extension staff working with schools to adopt STHS to discuss the types of training and resources that will be available to teachers and emphasize the alignment of STHS with TEKS as a way to enhance curricular alignment, and potential academic outcomes. These findings also echo prior implementation evaluation of civic engagement interventions to create health-focus changes to the built environment; important facilitators for success of these types of programs include securing stakeholder support (e.g., partners in the community that can mobilize resources to facilitate change) and being able to negotiate around time constraints (26, 39, 40).

Participants also noted, however, specific circumstances and contexts in four of the five domains that could act as barriers to implementation if not considered. A notable example is the continually shifting priorities of external partners such as SHACs, which as noted are obligated to reflect the values and priorities of local community residents. This is in line with previous research that identifies socio-political contexts and the priorities of the surrounding environment as possible barriers to implementation of school-based programs (22). This is also the space in which Texas Extension staff operate, as many of them serve on their SHAC. By working with extension agents to implement STHS, the research team can identify when schools and communities are interested in implementing health and positive youth development programs, as well as other circumstances where STHS may align with the needs and values of communities (e.g., wanting to offer an after school program). By providing unique insight into the priorities and amenability of their local SHACs and other potential implementation support, extension agents will thus be critical partners in tailoring STHS implementation plan to local contexts.

Another finding was that variability in teachers' or extension agents' experience was a potential barrier to implementing STHS. More specifically, participants stated that newer teachers and extension agents may not be as prepared to manage classroom time and/or students, and these topics were not covered in the curriculum materials. These results corroborate previous studies that also identified managing time and students as a challenge during the implementation of behavioral programs in schools (14, 15, 20). Some methods of addressing this concern may be to provide optional additional training, ancillary support materials, or additional implementation support from an experienced educator to help less experienced implementers with the program. Providing training for the STHS program was perceived as positive implementation support and is widely supported as a facilitator to successful school-based programs (22–24), both in the United States as well as international contexts (51, 52). By providing additional time management and classroom management strategies, the research team may be able to provide a more comprehensive and tailored training regimen that addresses potential barriers. In addition, training models that address diverse experience levels could be proposed.

The application of CFIR to these interviews yielded useful information to contextualize the program and provide potential ways to improve the implementation of STHS at different levels of influence, which can lead to designing programs that are more practical, scalable, and impactful for the school context. Although the study revolved around one specific evidence-based program (i.e., STHS), the findings may be applied to a wider array of school-based programs that focus on PA, healthy eating, and/or positive youth development. For example, identified challenges that result in variations in implementation fidelity of after-school programs or inconsistency of community boards, such as SHACs, are likely to be issues that are encountered by many researchers and practitioners delivering programs in the school setting. Additionally, the need for training to implement programs, sensitivity to limited instructional time, and accommodation of varying teacher experience levels are also factors found here that are not unique to STHS or the Texas public education system. However, future research is needed to better understand and test the relationships between the barriers identified here and various implementation outcomes (e.g., adoption, fidelity, sustainability).

Participants in this study reviewed only two sessions of the full STHS curriculum to provide feedback, and provided with a verbal overview of the entire program. Their perceptions of the program's usefulness, barriers, and facilitators of implementation are limited in this way. However, given the consistency in the comments across interviews that formed, and the themes discussed here, the authors are confident that the findings reflect the overall STHS curriculum and its potential for implementation. Interviews did not consider the perspectives of all people involved with STHS's delivery (e.g., students, parents, school health advisory council members). Although these individuals' perspectives are important, they may not apply to all aspects of the implementation process (e.g., use of the implementation guide, classroom management), and as a result, they are not included here. Future studies providing a more comprehensive perspective of all stakeholders are needed.

Despite not including all pertinent stakeholder groups, as mentioned above, interview participants presented a useful sampling of potential innovation deliverers, facilitators, and support personnel that gave comprehensive feedback on all aspects of the CFIR framework. Another strength was the use of inductive coding, followed by deductive CFIR coding, which allowed the research team to find emergent barriers and facilitators that may not have been captured by an exclusively deductive coding process, which may be overly constrained by a priori categories and ideas. Finally, having participants identify potential barriers before STHS implementation and evaluation allowed the team to pre-emptively change the curriculum and the implementation strategies (e.g., developing additional classroom management training materials) before evaluating it in a randomized controlled trial.

According to Extension staff and school staff members, STHS provides a comprehensive and accessible intervention for improving middle-schooler nutrition and PA knowledge. Many aspects of the program address existing needs and are tailored to overcome implementation barriers for school-based interventions, as recognized by participants who felt the useability of the curriculum and the alignment with teaching standards were advantageous. Further refinement of the implementation process of STHS could be accomplished through additional strategizing with local community advisory boards (e.g., SHACs) and targeted training that is more responsive to educators' needs.