Multi-level factors influencing the implementation of Cambodia’s National Policy on School Health: a qualitative case study

BACKGROUND: Since the 2000 World Education Forum, international organizations have encouraged low- and middle-income countries to strengthen school health systems through national school health policies based on the Health Promoting School (HPS) concept. While these policies offer proven benefits, implementation remains challenging in many low- and middle-income settings. In Cambodia, despite the establishment of the National Policy on School Health (NPSH), implementation remains uneven and insufficient across administrative levels. While implementation factors have been identified at the national, provincial, and elementary school levels, evidence remains limited at the secondary school level. Therefore, the current study investigated the factors influencing NPSH implementation at the public secondary school level in Battambang province. METHODS: This qualitative case study assessed complementary information from 27 key informant interviews (KIIs) with stakeholders involved in policy implementation and 13 documents related to previous implementation efforts. Participants represented national policy, provincial, district, commune, and school perspectives. Content analysis combined deductive coding guided by Vince Whitman's wheel of factors influencing the implementation of policy and practice, with inductive coding of context-specific themes. RESULTS: Nine thematic domains were identified to influence NPSH implementation. Policy reform, policy implementation-adapted strategy, and champions and leaders at all levels were described primarily as enabling implementation. Dissemination gaps and limited understanding within the international and national guidelines domain, attention to external forces, and gender gap and mandated roles were described primarily as inhibitors. Dedicated time and resources, administrative and management support, and stakeholder ownership and participation contained both enabling and constraining processes. These categories describe reported implementation experience rather than measured effect or the relative importance of factors. CONCLUSIONS: Participants described an interaction between a binding legal mandate and perceived local autonomy in the implementation of NPSH. Their accounts suggest that a clearer legal framework, support for local adaptation, leadership, and cross-sector participation may help implementation in this setting. This study did not establish causal effects or examine students' health and learning outcomes. Research across additional provinces, incorporating frontline staff, parents, students, and independent implementation data, is needed to assess the interpretations and their transferability.