The results are presented in two parts to address the primary and secondary purposes of the research. First, we present a national perspective on the essential conditions and describe the modifications to the existing core and contextual conditions as well as present a new condition. Then we outline participants’ views on the need and format of an evaluative tool to assess the implementation of the essential conditions. Direct quotes from CSH stakeholders are used to support the results. Additionally, the modified essential conditions (in the form of an infographic) are summarized in Figure 1.
Overall Perspectives on the Essential Conditions
Overall, participants from across Canada provided positive support for the essential conditions. The core and contextual conditions resonated with stakeholders involved in CSH at various levels. Participants expressed a general sense of gratitude that there was evidence to support what they had been doing in their school communities relating to CSH. For instance, Participant 20 said, “I just felt like oh my gosh, someone has actually captured our experience and in a way that we can understand it, and share it, and communicate it with our various organizations, or our community partners, or our school folks.” Further, participants felt that the essential conditions captured ‘what it takes’ to implement CSH and were practical guidelines for individuals working with staff and schools. Again, they particularly liked that the essential conditions provided evidence for implementation. One program director stated that “they’re easy to use, they’re easy to tailor, they’re easy to bring up as something that’s more tangible than just so-and-so’s word” (P31). Despite the variation across the country in terms of context, resources, and support available for CSH, the essential conditions were perceived as key factors that would support successful implementation of CSH.
Participants recognized the multiple layers of involvement required to successfully implement CSH and agreed with the breadth of the essential conditions. They highlighted a strength of the essential conditions was that it included all of the necessary people involved from students and teachers to the community and funders. Participant 12 explained that with the essential conditions “none are non-essential. Some will play a more important role at different times. I think in order to be truly comprehensive all those things need to sort of align in some way…It’s a complicated process.”
Many participants also noted the interconnectedness of the core conditions and contextual conditions. Specifically, participants noted that missing one condition could make the entire implementation process more challenging, thus highlighting the need for all conditions to be present. A participant involved in CSH at the ministry level explained how the “relationships between some of these conditions are absolutely contingent on others -- and not in a very easy to explain linear way -- but there's certainly strong relationships between them” (P3). Multiple participants echoed these remarks regarding the intricate nature of the essential conditions. Participant 44 stated, “what is helpful about the core conditions and the contextual conditions idea is that they are simplifying an area that is very complex and nuanced.”
It is clear from the participants’ views that the original seven essential conditions were positively perceived. However, participants made several suggestions for modifications to improve the clarity and refine the conditions to best represent what is needed to implement CSH in school communities across the country (see Table 1 for a summary).
Table 1. Modifications to the essential core conditions
Theme
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Modification
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Representative Quote
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Students as Change Agents
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More emphasis on students’ voice
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“I wonder about the student as change agent, the title is great, but it doesn’t, to me, it doesn’t get at student empowerment. I think if you can just tweak the language a tiny bit to bring out the student voice, so the students as leaders, so they are change agents” (P24).
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Clarify that students are change agents within the school through peer-to-peer interactions
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“They [students] are much more likely to listen; they are much more likely to think about this [CSH] seriously when it’s coming from students from different grades” (P12).
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School-specific Autonomy
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Explicitly include school culture
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“It's probably a good idea to put a line in or a nuance in the school specific autonomy piece that recognizes cultural – various cultural influences in the demographic or something of the school” (P20).
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Demonstrated Administrative Leadership
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No modifications made
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“The role of principals, I 100% agree” (P41).
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Higher-level Support
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New essential condition:
Support and leadership from school district and government ministries
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“The perfect situation is if you have leadership at the province and then you have leadership buying-in at the district level too… I think that having that district level support and that consistent, like not just a one-off, a consistent support and actually making room for it in the pile of many things, needs to be done” (P24).
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implementation of policy at the district and ministerial levels
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“We've heard from the schools and from teachers time and again that it's not going to happen, it's not going to work until there is some kind of policy. And what I mean by that is until the Department of Education basically mandates that schools take this on, it's not going to happen, which I didn’t see reflected in the essential conditions” (P1).
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Maintain balance between building accountability around CSH and school autonomy
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“I think in some ways what we have right now in the CSH world or school health world is we have so much school-specific autonomy that we aren’t getting the systems change. So every school is doing their own thing and every school is doing something different. So I think there’s a really interesting balance there when we want to change things at a systems or a district level or a provincial level where we need to respect that autonomy” (P44).
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Dedicate School Champion(s) to Engage School Community
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Pluralize champion to reflect the team of champions that lead CSH
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“I would definitely put champions – just make that plural” (P18).
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Engage the school community rather than just the school staff
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“You need to have a champion pushing things within the community, and schools are communities so it would make sense that it’s community not just teachers” (P36).
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Community Support
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Broaden definition to include parents/families
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“We say school community and hope that people realize it means home, school, and community broader than outside those four walls. So that might be a tweak, you know. I think that parents defined in there or families defined in there could strengthen it” (P31).
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Quality and Use of Evidence
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Collect data that is context-specific and meaningful to the school
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“I think the big thing about evidence is that we need it to be local and meaningful. We need to give assistance in helping it be understood and just put into context and I think we are, we’re working harder to do that and to show places where the indicators and the core measurements are helping align with initiatives that are important to those who we are passing that data on to so that it becomes more meaningful to them. And then it becomes useful in a way by which therefore they want to monitor it and understand it (P4).
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Change definition to reflect the actual use of data
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“We collected this data, now we have a survey, what are the results, what do they mean and what are we going to do about it are really challenging in school communities. The challenge is on the back end and actually using it. A lot of the data is out there, it’s just not being used” (P44).
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Professional Development
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No modifications made
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“I would say that professional development needs to be a core condition. They're not trained in this area of health necessarily. So they need that professional development to be able to fully understand why this [CSH] is important and buy in. To be those champions. To share it with their students, to share it with others in the school, to be able to speak the language and understand why the connection between being healthy and being able to learn” (P20).
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Modifications to the Essential Conditions
Students as Change Agents. Participants thought Students as Change Agents was essential for implementing CSH but felt the notion of students’ voices was left out of the description. Participants thought students’ voice needed to be included in the statement because students are at the heart of CSH and their voices give them a stronger sense of ownership and empowerment within the school community. Closely tied to student voice was student leadership. Like many stakeholders involved in CSH at all levels, Participant 7 stated, “change is definitely more profound if the youth have the leadership role and are supported by adults.”
The last modification suggested was to clarify that students are change agents within the school through peer-to-peer interactions, not just change agents to the home environment, which was the focus of the existing definition. Participants recognized the importance of parental buy-in and students’ roles in driving this change at home, but thought there should be more emphasis on being drivers of change at school. It was also evident that peer interaction drove change within school communities. Participant 23 said: “students have said to us before that they're more likely to want to be involved in something or want to make changes when their peers are initiating it and are involved rather than adults telling them what to do.”
School-specific Autonomy. All participants agreed that school-specific autonomy was “absolutely critical” (P5) for implementing CSH. One point raised by many stakeholders, particularly those engaged in CSH at the government level, was around school culture and cultural considerations and that this needed to be explicitly stated in the definition. For example, Participant 23 said, "You might have a word in there that includes like when you’re meeting the needs of the school, the culture, the socioeconomic make-up, like everything, identities of the students and things like that. I think that needs to be included there." However, it was evident from participants who were involved in CSH at a school community level, that the notion of culture was already embedded in the autotomy of the school. In essence, these participants were already making geographical, historical, and sociocultural considerations. Participants also mentioned that regardless of the type of school (e.g., on-reserve schools, Catholic schools, French immersion schools, public schools) or geographic locale (e.g., rural, urban) CSH still ‘works’ because “that school-specific autonomy allows for that flexibility” (P31) and cultural considerations are part of making an individual school plan. Although most CSH stakeholders perceived cultural considerations to already be included in the definition of school-specific autonomy, the description has now been modified to explicitly include it.
Demonstrated Administrative Leadership. All participants fully supported the title and definition for the essential condition of demonstrated administrative leadership. No suggestions for modifications were made. From all levels of CSH involvement, stakeholder participants agreed, “if you don’t have the principals on-board you have nobody. You’re not getting in the door” (P29). They also thought that administrators needing to be actively engaged was an essential component of the description. Participant 25 explained, “I liked how you put in that the key of the principal, that they’re actively engaged, not merely coerced by the school champions and just passively saying, ‘yeah, do whatever you want’.”
New Essential Condition: Higher-level Support. Stakeholders engaged in CSH strongly believed that an essential condition pertaining to higher-level support was missing. Participants, both at the government level and in school communities, discussed the need for support above the administrative leadership team. Participant 29 stressed the importance of higher-level support. She said, "You really have to have a buy-in and commitment to CSH at the policy decision making level because even if a principal agrees, if the board says ‘no we don’t have time for this’, then they have to say no” (P29). Participants felt that shared and coherent priorities across all levels (i.e., school district, and government ministries) were needed for CSH implementation to be successful.
In addition to leadership and support from multiple higher levels, several participants thought the implementation of policy at the district and ministerial levels around CSH was needed. With a policy in place, they thought there would be accountability for school boards and school communities to follow through with implementing CSH. However, participants were quite cognizant of the need to maintain balance between a top down and bottom up approach in order to safeguard schools’ autonomy while also building accountability around CSH. Participant 3 said, “it's that combination of permission from the top that we're going to do something and direction that this is important but also giving schools, at the ground level, all the flexibility to do it in a way that works for them” (P3). Therefore, based on what CSH stakeholder participants reported, higher-level support was created as a new core condition.
Dedicated School Champion(s) to Engage School Community. Participants suggested two small changes to this core condition, both of which related to the title. First, participants thought it should be pluralized to reflect the team of champions that often lead CSH in a school community. Participants also felt that teamwork was a helpful strategy for a CSH approach, especially in school communities where there was no health champion position and multiple individuals worked together. As Participant 20 indicated, “I think CSH is more successful when there is a team of champions.” The other change reflected in the title of this core condition is to engage the school community rather than just the school staff. It is important that the team of school health champions aim to engage all of those who are part of the school community including students, teachers, staff, parents, and the wider community.
Community Support. Community support was an essential condition that participants in all contexts across Canada supported. It was perceived as crucial for CSH success and sustainability. Participants described community support and active engagement from public health, students, and parents “as the secret sauce. The more people that you're involving in the conversations, the better this will be for everyone” (P39). While everyone agreed that community support was imperative and the title of the condition remained unchanged, participants felt the definition needed to be broadened to specifically identify parents and families because they play an important role in supporting CSH and may not always be included in ‘community’. This modification was clearly indicated by Participant 18 who stated, “parents are a critical piece… I put them [parents] under community support, but maybe you’ve ought to be more explicit on parents” (P18).
Quality and Use of Evidence. All stakeholders mentioned that evidence was valuable in all stages of CSH. It was necessary for planning CSH in order to identify specific strengths and needs of the school community and was indispensable for implementation to assess what conditions were in place. Specifically, school-based evidence was key to evaluating CSH progress so changes could be made and new goals set, or simply put; planning, refining, and supporting implementation. One principal summarized the value of evidence in shaping CSH in her school. She said, “[evidence] has played a big role in what we do at times and other times it hasn’t played a big enough role. It waxes and wanes but it is the best way, I think, to know if something is working and also the best way to get ideas for the next step” (P10). Participants indicated the essential value of evidence to CSH, however, many participants also indicated that while data were available, it was not often used. Participant 32 was quite straight forward when admitting “yes there’s evidence, the problem with evidence is it’s not used.” The actual use of data that were readily collected and available appeared to be a challenge for school communities.
A further challenge with using data was that it is often collected on a provincial or territorial level rather than at the school level. As such, participants explained that evidence needed to be context-specific and be meaningful to the school community. Further, participants indicated that quality evidence meant that it was more than just survey data. Specially, they argued that some of the most meaningful data came from qualitative assessments with students. Based on these issues with evidence, the title of the essential condition has been modified to emphasize that data needs to be of meaningful quality, and once collected, it needs to be used in a manner that actually informs implementation.
Professional Development. Participants thought professional development (PD) was an important aspect of implementing CSH, however, there were competing thoughts as to whether PD should remain a core condition or be moved to a contextual condition. Several participants felt PD would fit better as a contextual condition because PD was not perceived to be as necessary as some of the other core conditions like school-specific autonomy and administrative leadership. When asked why it should be moved to contextual conditions, Participant 15 said PD “is definitely helpful but I wouldn’t say that it’s as much of a priority as the other pieces.” Further, participants thought PD was not necessarily required to implement CSH and saw it more of a ‘bonus’ for teachers. One the contrary, several participants believed PD was essential to the success of implementation and should stay a core condition. As Participant 13 commented, “PD is absolutely critical for promoting school health. We’re not all wellness experts on our own.” They thought on-going training and education on what CSH is and why it is valuable was important to develop administrators’, teachers’, and school board staff’s knowledge and skills around CSH and build their capacity to do the work.
Contextual Conditions. Overall, CSH stakeholder participants perceived the contextual conditions to accurately influence the ability of the core conditions to be met. They agreed with the contextual conditions of time, and funding and project support but felt it was necessary to have readiness and understanding and prior community connectivity as separate contextual conditions.
In terms of time, this contextual condition did not change. Participants reported that time significantly influenced the implementation of CSH. The biggest challenge was having the time to plan and implement, because without enough time, CSH implementation would not be done well or be successful. Participant 12 said that time was needed to “sit down, actually create some things. Having time to meet with students, have time to meet with other staff. And, of course, the time to bring parents in and community members to come be part of what’s happening in the school because, of course, everyone is busy; not just teachers.” Lastly, participants believed that time needed to be set aside for the multitude of tasks associated with implementing CSH.
Funding and project support was viewed as a significant resource for CSH implementation. This was indicated by one participant who said, “I think sometimes funding and supports really can make or break it” (P6). Funding and support was seen to influence almost all of the core conditions. It provides financial support for professional development such as release time for teachers, funds to support new initiatives or programs within a CSH approach and provides assistance to school health champions. Although a few participants suggested that funding and project support could be considered a core condition, Participant 24 said “I think those funding and project supports are contextual, they can be helpful, but if people want to do the work then they often find a way to do it.”
While they agreed with their importance, many participants thought readiness and understanding and prior community connectivity were unique and wondered why the two were combined as one contextual condition. “…why are those together? I think there's too much to think about in a contextual condition. They should be separate ‘cause readiness alone is a pretty huge factor” (P2). Participants suggested separating ‘readiness and understanding’ and ‘prior community connectivity’ into their own contextual condition because on its own, they thought, “the readiness piece is huge, some schools just aren’t ready to be doing anything different than what they are” (P25). Readiness alone was seen as an imperative ‘first-step’ to engage in CSH and to change the school culture. One aspect of readiness that participants felt strongly about was having a shared understanding of CSH and how it connects to health and well-being in school communities. A teacher summarized the contextual condition of readiness and understanding best when she said, “if they don’t know about all this [CSH] stuff, how could they ever be ready? But I think they have to at least be ready or open to change” (P8). As such, the contextual condition of readiness and understanding describes the need for school communities to have a clear understanding of CSH and why it is important in supporting readiness for CSH implementation.
In support of the decision to separate these two contextual conditions, one participant stated, “I'd essentially think of them as two, kind of this idea of readiness to take on this approach and kind of embed this approach in what they're doing, and then this idea of, you know, how do you start to engage the community in this work” (P19). Specifically, in relation to prior community connectivity, participants agreed that it could influence the core conditions, but perhaps not to the same extent as readiness, time, and support. One teacher said, “I don’t know that prior community connectivity is as big a piece but it definitely helps that they make those moves once they’re ready to go. It makes the things move faster it they have prior community connections” (P8).
Tool Development
Participants identified four key themes for the development of an evaluative tool. These included the format of the tool, the intent of the tool, identifying indicators, and using a team approach (see Table 2 for a summary).
Table 2. Development and format of evaluative tool themes
Theme
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Description
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Representative Quote
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Format
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The format of the tool needs to be user-friendly, concise, and available online.
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“I think, to be honest, maybe the best way to do this is creating a tool that’s both able to be completed on paper as well as on like on an iPad or Smart Board or a computer, like digital, so that it can support wherever the school is at with their technology” (P34).
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Intent
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The tool should provide a clear idea of a school’s progress with implementation of the essential conditions.
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“It has to be very easy to use, quick to use, has to get the information back to them [school health champions] as well in a way that they can use the information…It can't just be sort of one-way information. It'd have to have a clear connection in terms of how is that tool supporting us and our schools to be able to be moving forward” (P3).
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Indicators
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CSH progress should be measured on a continuum with clear indication of what successful implementation looks like.
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“You need that criterion so it's outcome-based. What outcomes are you going to see if you're at 100%? What outcomes are you going to see at 50%?...If I'm somebody that strives for excellence, I'm going to start looking at the criteria and say those are the outcomes that need to occur and then that's what I'm going to strive for” (P30).
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Team Approach
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The tool should be designed in such a way that a team could complete it together.
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“[The tool should be] a digital type thing that students and staff do together” (P37).
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Format. Almost all participants believed a tool that could establish readiness and evaluate and assess the implementation of the essential conditions would be beneficial to school communities. One of the issues discussed by participants, which also closely related to the core condition of evidence, was that there was often not any reflection or evaluation of how a school was doing in terms of CSH implementation. It was clear from participants’ responses that there was a definite need for an evaluative tool, and participants across all levels of CSH stressed the importance of the format of the tool. Specifically, participants thought the development of an evaluative tool should be user-friendly and concise. For example, they said an evaluative tool “just needs to be quick and easy” (P20) and “something short and sweet” (P29). Participants also provided practical suggestions for the design and delivery of an evaluative tool. These included being available online and in paper format, as well as being available in multiple languages. Participant 40 described some of the key factors to consider:
It has to be online, it has to be in English and French, it has to be accessible in multiple languages. I think that it has to be really simple and it cannot be onerous. So I think that those would be some of your essential things that you need to be thinking about.
Intent. In addition to be a relatively short tool, participants also felt an evaluative tool should provide a clear idea of a school’s progress with implementation of the essential conditions. Participant 21 said the tool should “provide accuracy but be fairly simple and not very time-consuming… If it captures snapshots of progress or successes, or gaps and failures too, like that would be incredible.” A key point made by participants was the notion that the tool would need to provide immediate information to schools related to each of the essential conditions. After completing the tool, the feedback would indicate where a school is at, and possibly provide resources and ideas to improve or continue with implementation success for each condition. As Participant 27 suggested, the tool would be “something that you would fill out and then it could give you maybe a breakdown of areas that need to then be worked on, and resources and tips for doing so. It’s just essential that there’s feedback right away that addresses some of those areas and gives ideas for how to do better." Participants also indicated that these resources could be somewhat of an “idea bank” (P14) that would provide a list of examples and strategies other schools have used who have experienced success in implementation of the essential conditions. While the list would not be exhaustive, participants thought it would be useful if it could provide some novel ideas for schools.
Indicators. Participants suggested that progress should be measured on a continuum rather than a score or number. Different ideas were put forward but were similar in the sense that successful implementation of the essential conditions and creating a healthy school community was a process that took time. One participant said, “I’d really like if it gave you a snapshot of where you might be on a continuum, on a road to healthier school communities. I like the notion of kind of giving you some suggestions on tips on either how you continue to improve or what you might want to look at doing that you’re not doing” (P40). Likewise, Participant 23 provided a detailed description of what such a continuum could look like. She explained the ‘stages’ of implementation could be:
You know, ‘initial implementation’ or ‘initial stage’, then ‘further along’ [laughs] I don’t know what you would call it; and then like ‘fully implemented’. So some kind of scale like that that sort of says where they are at on the journey; or like ‘not at all’, like that might be the first one.
One necessary component of an evaluative tool that participants thought was important was indicators of successful implementation. This was especially important because there could be a lot of interpretation around what each essential condition could look like in practicality in a school. For example, several participants explained what student engagement looked like in one school community could be drastically different in another school community but both may think they have fully implemented the essential condition. Thus, having clear indicators for each essential condition would help in the creation of an evaluative tool.
Team Approach. The last important consideration for developing an evaluative tool was that the tool be designed in such a way that a team could complete it. This aligns with the suggestion made earlier that the dedicated champion condition should be modified to dedicated champion(s) to engage school staff since a team approach is often the case when implementing CSH. Participant 2 said, “I think if you're thinking of a tool, using a team approach is right. A tool that a team would use to evaluate where they're at or an administrative team from a school to assess their stage of readiness.” Given successful implementation of the essential conditions for CSH encourages a team of dedicated health champions, the design of an evaluative tool should be made with this in mind.