Multi-level factors influencing the implementation of Cambodia's National Policy on School Health: a qualitative case study.
8 affiliations
- 1Department of Global Health, Graduate School of Health Sciences, University of the Ryukyus, Ginowan, Okinawa, 901-2720, Japan. [email protected].
- 2Department of Science, Faculty of Science Education, Battambang Teacher Education College, Battambang City, Battambang Province, 020-30304, Cambodia. [email protected].
- 3Battambang Teacher Education College, Battambang City, Battambang Province, 020-30304, Cambodia.
- 4The Global Collaboration in Nursing Research Division, Shiga University of Medical Science, Ōtsu, 520-2192, Japan.
- 5Curriculum and Instruction Unit, Kampot Provincial Teacher Training Center, Kampot City, Kampot Province, 070-80100, Cambodia.
- 6The United Graduate School of Education, Tokyo Gakugei University, Koganei, Tokyo, 184-8501, Japan.
- 7Department of Global Health, Graduate School of Health Sciences, University of the Ryukyus, Ginowan, Okinawa, 901-2720, Japan.
- 8Japanese Consortium for Global School Health Research, Ginowan, Okinawa, 901-2720, Japan.
Abstract
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.
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BibTeX
@article{pheng2026multilevel,
title = {{Multi-level factors influencing the implementation of Cambodia's National Policy on School Health: a qualitative case study.}},
author = {Saray Pheng and Vandy Tep and Takashi Asakura and Sokhom Chan and Marie Ueno and Noudéhouénou Credo Adelphe Ahissou and Jun Kobayashi},
journal = {Tropical medicine and health},
year = {2026},
month = oct,
doi = {10.1186/s41182-026-01103-5},
url = {https://europepmc.org/article/MED/42958548},
note = {CC BY},
}
RIS
TY - JOUR
TI - Multi-level factors influencing the implementation of Cambodia's National Policy on School Health: a qualitative case study.
AU - Saray Pheng
AU - Vandy Tep
AU - Takashi Asakura
AU - Sokhom Chan
AU - Marie Ueno
AU - Noudéhouénou Credo Adelphe Ahissou
AU - Jun Kobayashi
PY - 2026
DA - 2026/10/01
JO - Tropical medicine and health
DO - 10.1186/s41182-026-01103-5
UR - https://europepmc.org/article/MED/42958548
AB - 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.
SN - 1348-8945
SN - 1349-4147
ER -