The intersection of systems thinking and structural empowerment in the work of public health dietitians.

BACKGROUND: Public health dietitians navigate complex professional landscapes amid dwindling resources, organisational disruptions and limited advancement opportunities. Cultivating systems thinking and structural empowerment competencies may enable this workforce to address multifaceted public health challenges more effectively. This study explored the extent to which public health dietitians apply systems thinking and perceive access to structural empowerment and the relationship between these constructs. METHODS: A quantitative online survey incorporating the systems thinking scale (STS) and conditions for work effectiveness questionnaire-II (CWEQ-II) was conducted among US public health dietitians who worked in governmental public health. Data were collected from September 2022 to October 2022. Descriptive and inferential statistical analyses were conducted. RESULTS: Among 216 respondents, 98% demonstrated moderate-to-high systems thinking competency (mean STS score = 60.3 ± 8.74, range 28-78). Over 88% reported moderate-to-high perceived structural empowerment (mean CWEQ-II score = 18.3 ± 0.96, range 8-29). Higher systems thinking scores were associated with greater decision-making authority (p = 0.01) but not budget oversight. Higher structural empowerment scores correlated with increased job responsibilities and decision-making authority (p < 0.001). A significant positive correlation existed between systems thinking and structural empowerment (r = 0.24, p < 0.001). Public health dietitians exhibited substantial systems thinking capabilities and perceived access to organisational power structures. CONCLUSIONS: This study offers baseline understanding of systems thinking and structural empowerment among public health dietitians. The positive interplay between these constructs underscores their potential to drive systems-level change and influence population health outcomes. Integrating systems thinking and structural empowerment into dietetic education and professional development may enhance the workforce's preparedness for navigating complexities.

Charting the Advocacy Landscape: A Qualitative Content Analysis of Syllabi in Public Health Graduate Education.

CONTEXT: Addressing public health challenges necessitates policy approaches, but concerns persist about public health graduates' preparedness to advocate. OBJECTIVE: This qualitative study sought to assess advocacy content and skills taught to Master of Public Health students enrolled in US accredited schools and programs of public health (SPPHs) by analyzing 98 course syllabi submitted to the Council on Education for Public Health (CEPH) between 2019 and 2021. Syllabi were submitted by SPPHs during their (re)accreditation process to demonstrate compliance with CEPH's advocacy competency requirement. DESIGN: Qualitative content analysis study. Syllabi were analyzed using MAXQDA Qualitative Data Analysis Software using a 2-coder approach. SETTING: SPPHs accredited by CEPH. PARTICIPANTS: Ninety-eight syllabi submitted to CEPH by 22 schools of public health and 54 programs of public health. MAIN OUTCOME MEASURES: Exemplary language from advocacy courses and assignments and aggregate frequency of syllabi advocacy content and skills. RESULTS: Most advocacy courses (61%) were survey, health policy, or health care delivery courses, covering policy (66%), policy communication (46%), coalition-building (45%), lobbying (36%), community organizing (33%), and media advocacy (24%) skills. Only 7% prioritized advocacy skill instruction, and 10% addressed how to advocate in an equitable way. CONCLUSIONS: Defining public health advocacy and essential skills is crucial. Issuing competency guidelines, supporting advocacy faculty, offering standardized training, and expanding experiential learning are important first steps. More research is needed on how academic institutions are incorporating equity skill training into courses, whether separate from or combined with advocacy skills.

Enhancing Adaptability: Exploring Structural Empowerment and Systems Thinking Among State Governmental Public Health Nutritionists.

This study explored how structural empowerment and systems thinking enabled public health nutritionists to adapt to complex environments. Interviews with 14 dietitian-prepared nutritionists from state governmental public health agencies elucidated 3 key themes: leveraging relationships was essential to exercising structural empowerment and systems thinking; accessing resources and support were priorities in supporting public health nutrition initiatives; and addressing gaps in formal training, specific to systems thinking, enabled adaptability to work in public health settings. The findings highlight the need for broader examinations into strengthening access to organizational power structures; integrating systems thinking into public health operations; and sustaining professional development for the public health workforce, especially with limited resources. Enhancing access to organizational power structures and applying systems thinking can empower the public health workforce to better adapt to challenges by building relationships, accessing resources and support, and making informed decisions that positively impact population health.

Opportunities to Improve Access to and Retention in the Child and Adult Care Food Program: Key Recommendations From Early Childcare Providers in Illinois, December 2020-July 2021.

Objectives. To identify recommendations to improve access to and retention in the Child and Adult Care Food Program (CACFP) as critical strategies to address health equity for low-income children. Methods. We conducted a qualitative key informant study of early childcare center and home providers (n = 35) in low-income urban and rural census tracts in Illinois between December 2020 and July 2021. Interviews with providers were organized and analyzed by the study team in MAXQDA Qualitative Data Analysis software. Themes were refined and finalized via member checking with an expert panel of providers and advocates. Results. Overall, providers spoke positively of the benefits of CACFP participation. Themes that centered around strategies to improve awareness of and access to CACFP included (1) conducting systematic statewide outreach, (2) improving technical assistance for enrollment, and (3) supporting positive sponsor-provider relationships. Themes related to retention included (1) alleviating procurement burdens, (2) extending reimbursement rates, and (3) expanding flexibilities. Conclusions. Policymakers looking to increase access to and retention in CACFP could consider state-level strategies such as systematic outreach and more targeted technical assistance. (Am J Public Health. 2024;113(S3):S231-S239. https://doi.org/10.2105/AJPH.2023.307433).

Facilitators and Barriers to Implementation and Sustainability of Nutrition and Physical Activity Interventions in Early Childcare Settings: a Systematic Review.

A stronger understanding of the factors influencing implementation of interventions in community-based early childcare settings is needed. The purpose of this systematic review was to synthesize existing research on facilitators and barriers to implementation and sustainability of nutrition and physical activity interventions in early childcare settings targeting 2-5-year-old children, including considerations for equitable implementation. This review adhered to PRISMA 2020 guidelines. Peer-reviewed literature was searched in PubMed, EMBASE, CINAHL, ERIC, and PsycINFO databases up to September 2020. Primary research studies that examined facilitators and barriers (or related synonyms) to the implementation and sustainability of nutrition and physical activity interventions in early childcare settings were eligible for inclusion. The search yielded 8092 records that were screened by four analysts in Covidence software with a final review of 24 studies. Two independent reviewers conducted study selection, data extraction, and quality appraisal (Mixed Methods Appraisal Tool). A "best fit" framework was applied using the Consolidated Framework for Implementation Research (CFIR) constructs to code barriers and facilitators. The most salient constructs were (1) "Available Resources," which was composed of time, staffing, space, and staff trainings; (2) adaptability; and (3) compatibility, the latter two indicating that easily modifiable interventions facilitated a smoother "fit" and were more likely to be successful, given adequate site-level resources. Only nine (28%) reported the use of a theory, model, or framework to guide evaluation; six studies (24%) included factors related to sustainability; and nine studies (38%) conducted their interventions with low-income or minoritized groups. The findings point to the need for intervention evaluations examining nutrition and physical activity to more consistently consider (a) sustainability factors early on in design and adoption phases; (b) use of theory, model, or framework to guide evaluation; and (c) equity-related frameworks and considerations for how equitable implementation.

"Holding the City's Feet to the Fire": Lessons Learned From Oakland's Implementation of Measure HH Sugar-Sweetened Beverage Tax.

CONTEXT: Sugar-sweetened beverage (SSB) taxes offer a promising public health strategy to decrease consumption of sugary beverages. To date, 7 US cities have successfully implemented SSB taxes; however, only a few studies have examined adoption and implementation processes. OBJECTIVES: To describe public health and policy lessons learned during the first 2.5 years of implementation of the Oakland, California, penny-per-ounce SSB tax, Measure HH. DESIGN: A mixed-methods, longitudinal, qualitative case study was conducted using a combination of key informant interviews with implementation stakeholders as well as analyses of archival documents and media documents from 2016 to 2019. Interviews were digitally recorded and professionally transcribed. Interview transcripts, archival documents, and media documents were analyzed by 3 coders using Atlas.ti v8. Analyses employed principles of constant comparative analysis to identify themes related to lessons learned. SETTING: Oakland, California. PARTICIPANTS: Key informants (n = 15), archival documents (n = 43), and media documents (n = 90). INTERVENTION: Oakland, California's SSB tax (Measure HH). RESULTS: Implementation lessons included both success stories and challenges. Successes included contracting a third-party tax administrator to support tax collection and education; leveraging a pro-tax coalition to counteract industry attacks and to protect tax revenue; and offering "quick win" funding to support local needs. Challenges were associated with implementing a "general" tax versus a "special" tax; the lack of explicit revenue allocation in the ordinance to support city-level implementation and oversight; and, the original ordinance language for tax application to distributors. CONCLUSIONS: The study offers a range of recommendations-derived from lessons learned over several years of implementation-to policy makers and advocates engaged in SSB tax adoption and implementation efforts in their jurisdictions. SSB tax implementation requires sufficient agency administrative capacity and a strong pro-tax coalition that engages local community organizations to respond to public health needs.

"On a Positive Path": School Superintendents' Perceptions of and Experiences With Local School Wellness Policy Implementation and Evaluation.

Renewed federal requirements for local school wellness policies highlighted the continued importance of supporting school districts as they implement and evaluate wellness initiatives. Superintendents-as school district leaders-play a critical role in wellness policy implementation and evaluation; however, to our knowledge, no studies examine their perspectives or experiences with the most recent federal rule or wellness initiatives more broadly. This study qualitatively examined superintendents' perspectives, experiences, and recommendations with wellness policy implementation and evaluation. Focus groups (n = 39) and follow-up interviews (n = 14 of the focus group participants) were conducted with superintendents from March to July 2017. Coders organized and coded transcript data using Atlas.ti, Version 8 to facilitate thematic analysis. Superintendents had overall positive perceptions of wellness policies and reported that implementation improved over time. Most described wellness approaches beyond typical wellness policy domains, including social-emotional learning and staff wellness. Evaluation of wellness policies was noted to be a challenge, and superintendents requested more tools and resources, as well as opportunities to learn from "best practices." Increased local and state accountability were recommended to facilitate motivation for other superintendents to engage with wellness. This study adds to the literature on a critical stakeholder in the school wellness field. Advocates and technical assistance providers can apply superintendents' recommendations to engage more district leaders in these initiatives.

Food and beverage marketing in schools: school superintendents' perspectives and practices after the healthy, Hunger-Free Kids Act.

OBJECTIVE: Children are surrounded by ubiquitous forms of unhealthy food marketing at home and in schools. The US Department of Agriculture now restricts food and beverage marketing that does not meet Smart Snacks in School standards. School superintendents, as districts' top administrators, play a critical role in ensuring marketing policies are implemented and adhered to; however, there is limited research involving this stakeholder group. The current study examined superintendents' perspectives on food marketing in schools and the marketing provision in wellness policies, as well as experiences with the implementation of such policies. DESIGN: Qualitative focus groups and follow-up interviews (with focus group participants) were conducted by trained researchers. SETTING: Focus groups occurred at The School Superintendents' annual meeting; follow-up interviews were over the telephone. PARTICIPANTS: Superintendents and assistant superintendents (n 39) from twenty-three states participated. Interviews were recorded and professionally transcribed; transcripts were team-coded in Atlas.ti using an iteratively revised coding guide to facilitate theme generation. RESULTS: Despite common concerns that marketing to children was 'insidious', superintendents reported a wide range of food and beverage marketing policies. In addition, the main issue is fundraising - such as 'restaurant nights' - that results in marketing that occurs on- and off-campus and afterschool. CONCLUSIONS: Discrepancies between perspectives and practices point to the challenges that superintendents face with budgetary constraints, as well as relationships with parent-teacher organisations. These findings provide important insights about superintendents' perspectives and challenges, particularly for government and child health advocates supporting school districts, to implement these policies.

USDA Snack Policy Implementation: Best Practices From the Front Lines, United States, 2013-2014.

INTRODUCTION: The Smart Snacks in Schools interim final rule was promulgated by the US Department of Agriculture (USDA) as authorized by the Healthy, Hunger-Free Kids Act of 2010 (PL 111-296) and implementation commenced beginning July 1, 2014; however, in the years leading up to this deadline, national studies suggested that most schools were far from meeting the USDA standards. Evidence to guide successful implementation of the standards is needed. This study examined snack policy implementation in exemplary high schools to learn best practices for implementation. METHODS: Guided by a multiple case study approach, school professionals (n = 37) from 9 high schools across 8 states were recruited to be interviewed about perceptions of school snack implementation; schools were selected using criterion sampling on the basis of the HealthierUS Schools Challenge: Smarter Lunchrooms (HUSSC: SL) database. Interview transcripts and internal documents were organized and coded in ATLAS.Ti v7; 2 researchers coded and analyzed data using a constant comparative analysis method to identify best practice themes. RESULTS: Best practices for snack policy implementation included incorporating the HUSSC: SL award's comprehensive wellness approach; leveraging state laws or district policies to reinforce snack reform initiatives; creating strong internal and external partnerships; and crafting positive and strategic communications. CONCLUSION: Implementation of snack policies requires evidence of successful experiences from those on the front lines. As federal, state, and local technical assistance entities work to ensure implementation of the Smart Snacks standards, these best practices provide strategies to facilitate the process.

Challenges and Opportunities for Equity in US School Meal Programs: A Scoping Review of Qualitative Literature Regarding the COVID-19 Emergency.

The emergency school meals program provided free meals to children in the United States (US) during COVID-19-related school closures. This scoping review aims to synthesize the existing qualitative empirical evidence published between March 2020 and January 2023 on the operations and utilization of emergency school meal programs during the pandemic. Qualitative, US-based peer-reviewed literature was collected from three sources: (1) parent review of all federal nutrition assistance programs; (2) systematic search of four databases; and (3) manual search of grey literature. Identified scientific articles and grey literature reports (n = 183) were uploaded into Covidence and screened for duplicates and inclusion/exclusion criteria. Our final sample included 21 articles/reports, including 14 mixed methods and seven qualitative-only projects. Articles spanned all U.S. states. Articles had similar research questions to understand school meals and/or general food access during COVID-19, with an emphasis on long-term policy implications. Hybrid deductive/inductive analytic coding was used to analyze data, utilizing domains from the Getting to Equity Framework (GTE). GTE considers multi-level factors that influence nutrition behavior while centering more equitable pathways to improve nutrition security and reduce adverse health. Findings were sorted into two categories: operational challenges during the pandemic and solutions to address inequities in school meal distribution during and after the pandemic, particularly during school closures such as summers or future emergencies. Key challenges related to supply chain issues, safety, and balancing families' needs with limited staff capacity. Programs addressed equity by (a) reducing deterrents through federally issued waivers and increased communications which allowed the serving of meals by programs to families who previously did not have access, (b) building community capacity through collaborations and partnerships which allowed for increased distribution, and (c) preparing and distributing healthy options unless barriers in supply chain superseded the effort. This review highlights the importance of emergency school meal programs and provides insights into addressing challenges and promoting equity in future out-of-school times. These insights could be applied to policy and practice change to optimize program budgets, increase reach equitably, and improve access to nutritious meals among populations at highest risk for nutrition insecurity.

Advancing the science of policy implementation: a call to action for the implementation science field.

Public policies have been essential in addressing many of the most pressing public health problems in the USA and around the world. A large and convincing body of multidisciplinary research has established the impacts or effectiveness of public policies, such as smoke-free air laws and nutrition standards, on improving health outcomes and behaviors. Most of this research assumes that because an evidence-based policy is adopted or takes effect, it is implemented as intended. This assumption, however, is often incorrect. Like with clinical guidelines and other interventions, implementation science has an important role to play in promoting the uptake and implementation of evidence-based public policies that promote public health. To realize this potential, there remains a critical need to first establish a common understanding of what public policy is, the role of specific policies in the context of implementation (i.e., is it the evidence-based intervention or the implementation strategy?), and to establish an appropriate methodological foundation for the field of policy implementation science. We recommend that the field must evolve to (i) include policy experts and actors on policy implementation science study teams; (ii) identify theories, models, and frameworks that are suitable for policy implementation science; (iii) identify policy implementation strategies; (iv) adapt and/or identify study designs best suited for policy implementation science research; and (v) identify appropriate policy implementation outcome measures.

Public policies are important to promote the health and well-being of the public. Many important health advances have been made because of policies designed to prevent or limit unhealthy behaviors (such as smoke-free laws) and promote access to medical care (such as health insurance mandates). However, just because a policy is "on the books" does not mean that it is implemented or implemented as intended. To improve how researchers study policy implementation, we discuss some challenges in the field, provide a call to action for researchers to continue developing the field of policy implementation science, and we recommend that scientists establish partnerships with experts in public policy and work together to develop scientific methods that will do a better job of putting policy into practice.

Applying hybrid effectiveness-implementation studies in equity-centered policy implementation science.

Policy implementation science (IS) is complex, dynamic, and fraught with unique study challenges that set it apart from biomedical or clinical research. One important consideration is the ways in which policy interacts with local contexts, such as power and social disadvantage (e.g., based on ability, race, class, sexual identity, geography). The complex nature of policy IS and the need for more intentional integration of equity principles into study approaches calls for creative adaptations to existing implementation science knowledge and guidance. Effectiveness-implementation hybrid studies were developed to enhance translation of clinical research by addressing research questions around the effectiveness of an intervention and its implementation in the same study. The original work on hybrid designs mainly focused on clinical experimental trials; however, over the last decade, researchers have applied it to a wide range of initiatives and contexts, including more widespread application in community-based studies. This perspectives article demonstrates how effectiveness-implementation hybrid studies can be adapted for and applied to equity-centered policy IS research. We draw upon principles of targeted universalism and Equity in Implementation Research frameworks to guide adaptations to hybrid study typologies, and suggest research and engagement activities to enhance equity considerations; for example, in the design and testing of implementing strategies. We also provide examples of equity-centered policy IS studies. As the field of policy IS rapidly evolves, these adapted hybrid type studies are offered to researchers as a starting guide.

Perceived factors that influence adoption, implementation and sustainability of an evidence-based intervention promoting healthful eating and physical activity in childcare centers in an urban area in the United States serving children from low-income, racially/ethnically diverse families.

Introduction: Early childcare centers offer optimal settings to provide healthy built environments where preschool age children spend a majority of their week. Many evidence-based interventions (EBIs) promoting healthful eating and physical activity for early childcare settings exist, but there is a limited understanding of how best to support adoption, implementation and sustainability in community settings. This study examined how early childcare teachers and administrators from Chicago-area childcare centers serving children from low-income, racially/ethnically diverse communities viewed an EBI called Hip to Health (H3), and the factors they perceived as relevant for EBI adoption, implementation, and sustainability. Methods: A multiple methods study including key informant interviews and a brief survey was conducted. Key informant interviews with teachers and administrators from childcare centers located in Chicago, IL were completed between December 2020 and May 2021. An interview guide and coding guide based on the Consolidated Framework for Implementation Research (CFIR) was developed. Interview transcripts were team coded in MAXQDA Qualitative Data Analysis software. Thematic analysis was used to identify findings specific to adoption, implementation, and sustainability. Participants were also asked to respond to survey measures about the acceptability, feasibility, and appropriateness of H3. Results: Overall, teachers (n = 20) and administrators (n = 16) agreed that H3 was acceptable, appropriate, and feasible. Low start-up costs, ease-of-use, adaptability, trialability, compatibility, and leadership engagement were important to EBI adoption. Timely and flexible training was critical to implementation. Participants noted sustainability was tied to low ongoing costs, access to ongoing support, and positive observable benefits for children and positive feedback from parents. Conclusions: These findings suggest that EBIs suitable for adoption, implementation, and sustainment in childcare centers serving racially/ethnically diverse, low-income families should be adaptable, easy to use, and low-cost (initial and ongoing). There is also some evidence from these findings of the heterogeneity that exists among childcare centers serving low-income families in that smaller, less resourced centers are often less aware of EBIs, and the preparation needed to implement EBIs. Future research should examine how to better support EBI dissemination and implementation to these settings.

Media Coverage and Framing of Oakland's Sugar-Sweetened Beverage Tax, 2016-2019.

PURPOSE: To describe media coverage and framing of Oakland, California's, sugar-sweetened beverage tax. DESIGN: Media content analysis. SAMPLE: Media documents (n = 90), published January 1, 2016-August 31, 2019, were retrieved from Oakland news outlets and ProQuest, NexusUni, EBSCO, and Google. ANALYSIS: Documents were coded using constant comparative analysis in Atlas.ti v8; with descriptive analyses conducted using Stata/SE v. 15.1. RESULTS: Documents were published evenly between pre- and post-ballot periods (n = 45); the majority (n = 47) provided neutral framing. Protax documents (n = 33) highlighted SSB consumption and health associations and countered antitax messaging; antitax documents (n = 10) focused on misinformation and sowing public confusion. CONCLUSION: Neutral media educates and raises awareness. Published prior to a vote, the media may help influence public opinion regarding SSB taxes. SSB tax media advocacy campaigns, giving particular attention to timing and perspective-based framing, may help to secure adoption and support implementation.

Can Monitoring Make It Happen? An Assessment of How Reporting, Monitoring, and Evaluation Can Support Local Wellness Policy Implementation in US Schools.

US school districts participating in federal child nutrition programs are required to develop a local wellness policy (LWP). Each district is allowed flexibility in policy development, including the approaches used for policy reporting, monitoring, and evaluation (RME). The aim of this convergent mixed-methods study was to quantitatively examine RME provisions in policies among a nationally representative sample of districts in the 2014-2015 school year in order to examine whether policies were associated with RME practices in those districts, and to qualitatively examine perceived challenges to RME practices. Data were compiled through the School Nutrition and Meal Cost Study and the National Wellness Policy Study. In multivariable regression models accounting for demographics, survey respondents were significantly more likely to report that their district had informed the public about LWP content and implementation, if there was a relevant policy provision in place. Having a strong policy (as compared to no policy) requiring evaluation was associated with reports that the district had indeed evaluated implementation. Having definitive/required provisions in policies was significantly associated with actual use of RME practices. RME activities are an important part of policy implementation, and these results show that policy provisions addressing RME activities must be written with strong language to require compliance. In interviews with 39 superintendents, many reported that RME activities are challenging, including difficulty determining how to monitor and show impact of their district's wellness initiatives. Furthermore, the qualitative results highlighted the need for vetted tools that are freely available, widely used, and feasible for districts to use in assessing their progress toward meeting the goals in their LWPs.

Oakland's Sugar-Sweetened Beverage Tax: Honoring the "Spirit" of the Ordinance Toward Equitable Implementation.

Purpose: On November 8, 2016, Oakland, California, voters passed a sugar-sweetened beverage (SSB) tax, which included language to support programs affecting communities and residents most affected by SSB-related health disparities. The purpose of this study was to qualitatively assess the extent to which those communities most affected by SSB-related health disparities were included in implementation decisions and were recipients of funding to support their needs. Methods: A longitudinal case study from 2016 to 2019 in Oakland, CA, explored equity implementation themes through key informant interview transcripts (n=15) triangulated with media (n=90) and archived documents (n=43). Using principals of constant comparative analysis, all documents (n=148) were coded and thematically analyzed in Atlas.ti. Results: SSB taxes-designed to support communities disproportionately impacted by SSB consumption-can be implemented with inclusivity and community representation. The Oakland ordinance established a Community Advisory Board (CAB) that partnered with community organizations throughout implementation to ensure inclusivity and recommend funding for programs to address health inequities, described as the "spirit" of the ordinance. These activities countered the beverage industry's tactics to target lower income communities of color with misinformation campaigns and hinder implementation. Conclusion: A clearly written ordinance provides guidance, which affords an intentional and legal foundation for implementation processes. Establishing a CAB can mitigate inequities as members are invested in the community and initiatives to support residents. Advisory boards are able to liaise between city and local partners, which is a powerful tool for countering opposition campaigns, reaching lower income and communities of color, and ensuring adherence to funding mandates.

Addressing Equity in Rural Schools: Opportunities and Challenges for School Meal Standards Implementation.

BACKGROUND: Few studies examine why rural public schools have weaker policies and practices related to school nutrition environments compared to their urban counterparts. It is important to understand this disparity because federal school meal standards aim for children to access health-promoting nutrition environments. In this study, we identify challenges and opportunities for the implementation of school meal standards in rural high schools. METHODS: We interviewed 38 rural school professionals from 22 high schools across 7 states. School professionals included food service directors, principals, school nurses, and teachers. Team coding in Atlas.ti Qualitative Data Analysis software v8 and principles of comparative analysis were employed to generate themes related to challenges and opportunities. RESULTS: Overall, school professionals described improvements with implementation experiences and student acceptance over time. Key challenges included the negative influences of home and community food environments and limited staff size and capacity. Key opportunities involved joining co-ops to enhance purchasing power, leveraging state technical assistance, and forming external partnerships. CONCLUSIONS: This study offers insights from a broad range of rural school professionals' implementation experiences. The findings can inform governments and technical assistance agencies working with rural schools and school districts to facilitate implementation and sustainability of initiatives.