Abstract
Support structures are available to schools worldwide for the implementation of Health Promoting School (HPS) programs. To get more insight in these structures, this multiple case study aimed to map variation in levels of support within eight Public Health Service (PHS) regions in the Netherlands and associations with contextual factors. Designed together with a Community of Practice, the study included two rounds of semistructured group interviews (N = 1-4 employees; ±3.5 hours per case) and document analysis. Data were collected on eight indicators of the level of support (e.g. intensity and reach) and 24 contextual factors relating to Healthy School Advisers, PHSs, stakeholder collaboration, and the wider context. Scores were assigned for all indicators and factors per region, and patterns were examined. Results showed large variation in the level of support across cases, mainly in intensity of provided support, integration in the PHS, and reach in terms of percentage of certified HPS schools. Some aspects such as advisers' context sensitivity scored low in all cases. Key contextual factors were related to the PHS: its policy, internal support, capacity, and (structural) budget. Other important factors related to collaboration with regional stakeholders: coordination, division of responsibilities, and communication structure. Structural budget and strategic stakeholder coordination could be improved in all cases. In conclusion, there is much room for improvement toward sufficient and higher quality HPS implementation support for all schools in the Netherlands. To strengthen support, it is important to establish commitment of the PHS organization, strong coordination between stakeholders, and strong national positioning of the HPS program. These conclusions might also apply to other countries.