Factors affecting school health policies and ways to improve them: a qualitative study

Abstract

Background

The health of school-aged individuals significantly impacts a country’s success and development. Numerous policies and programs have been implemented globally to enhance school health, influenced by various factors. This study aims to identify the factors affecting school health policies and explore ways to improve them.

Methods

This qualitative study was conducted in 2022 using semi-structured interviews. Participants included managers, policymakers, and health workers in schools, selected through purposive sampling. The data collection tool was a semi-structured interview guide developed by the research team. Interviews were conducted both in person and via telephone. The framework analysis method was employed to interpret the interview data.

Results

The study examined various facets of the issue, including the identification and analysis of beneficiaries, background factors, the policymaking process, and the content of school health policies. Proposed solutions included fostering a culture of improving school health, integrating policies and programs, securing financial resources, engaging relevant bodies and organizations, taking a macro-level view of school health, and ensuring adequate infrastructure and specialized human resources.

Conclusion

Developing need-based policies for students, promoting inter-organizational and inter-departmental cooperation among school health stakeholders, securing financial resources and environmental infrastructure, leveraging technology, and prioritizing school health are crucial. This underscores the importance of utilizing the latest scientific evidence to inform policy content and implementation.

Background

According to the Ottawa Charter for Health Promotion (1986), created by the World Health Organization (WHO) during the first International Conference on Health Promotion, key strategies for health promotion include building healthy public policy, creating supportive environments, strengthening community actions, developing personal skills, and reorienting health services. These strategies underscore the holistic nature of health promotion, addressing not only individual behaviors but also the structural and systemic factors that influence health outcomes [1]. Health promotion for students in schools is particularly important due to varying lifestyles, the influence of advancing technology, and the students’ expectations of their parents and educational systems.

According to the WHO, school health is defined as “a combination of learning and non-learning activities that address the health and well-being needs of students, teachers, and the entire school community.” The WHO emphasizes that schools should create an environment that promotes well-being through health education, health services, and supportive policies [2]. The health of school-aged individuals is crucial for the success and development of a country, as students learn healthy behaviors and shape their lifestyles through interactions with peers and teachers in school [3]. Therefore, it is essential to focus on providing students with the highest level of physical, mental, social, and spiritual health to achieve development goals [4].

A school is an institution with an educational and learning function; therefore, it is crucial to consider the health of all its components, including students, parents, and the school’s physical and social environment. Studies indicate that the risk factors associated with students are on the rise, leading to an increase in chronic diseases and risky behaviors, and hindering their ability to play a constructive and positive role in society [3, 5–7]. Consequently, ensuring the health of students should be a priority for health-related organizations, such as the Ministry of Health and the Ministry of Education.

To promote the health of students in schools, various policies and programs have been developed globally. In 2001, the WHO initiated a school-based care program in collaboration with international stakeholders, aimed at updating health information for students, parents, and school staff. In December 2005, a consultative meeting on health-promoting schools was organized to identify the best approaches for designing a network of health-promoting schools in the Mediterranean region. This program has served as an effective tool for establishing priorities, securing resources, and implementing programs for adolescents and schools, while also facilitating the exchange of ideas among different countries [8]. The program of health promoting schools is being implemented in all member countries of WHO except Afghanistan and Libya in the Eastern Mediterranean region [9].

The Comprehensive Health Program is another initiative within these efforts. This program encompasses various dimensions of health in educational settings, addressing aspects such as the school environment, the awareness of school staff and students’ parents, physical and social health, and the monitoring of concerning health trends, such as poor personal hygiene, inactivity, and smoking [10]. Providing students with adequate health and care resources during their school years can lead to positive outcomes, enhance their potential, and help prevent academic failure and the misuse of resources [11]. Therefore, implementing effective preventive policies can yield significant economic and social benefits for this demographic group and for global health as a whole [12].

An examination of school health policies and programs reveals that several factors play a crucial role in their formulation. One useful framework for cost analysis is the policy triangle developed by Walt and Gilson. This model aids in identifying and analyzing the key components that influence health policies. By exploring policy content, context, formation processes, and the role of policy actors, this framework offers a robust basis for the analysis and evaluation of health policies across various domains [13].

A review of existing studies indicates that numerous research efforts have addressed the development of models for school health policies. Notable examples include a study by Solhi and Abolfathi, which examined the impact of education on addiction prevention through the Health Belief Model (HBM) and its effect on the knowledge and perceptions of high school students [14]. Additionally, Hoveyzi et al. evaluated the implementation of the “Health Promoting Schools” program in Ahvaz [15], while Hung et al. explored the factors that enable health promoters to implement health-promoting schools [6]. Langford et al. focused on obesity prevention [16]. However, no qualitative studies have yet investigated the factors influencing school health policies using a policy analysis framework. Therefore, this study aims to identify the factors affecting school health policies and propose ways to enhance them.

Methods

This qualitative study was conducted in 2022 through interviews with informants.

Informants

The participants in this research consisted of managers and policymakers from the Ministry of Health and the Ministry of Education, health policymakers from medical universities, and staff from health units within universities of medical sciences. To qualify for the study, participants were required to meet several specific criteria: they needed at least five years of professional experience in school health policymaking, a willingness to participate, relevant education and expertise in school health policy, and a publication record that included at least one book, article, or research project related to school health policymaking. These criteria were designed to ensure that participants possessed the necessary experience and knowledge to provide valuable insights into the formulation and implementation of school health policies. A purposive sampling method, specifically an inhomogeneous approach, was used to select the key informants. This technique allowed for a diverse range of perspectives from individuals with varying roles and experiences within the field of school health. The aim was to gather a broad spectrum of insights that could effectively inform the research objectives. A total of 14 interviews were conducted for this study. Data collection concluded once a point of saturation was reached, which was determined when no new themes, insights, or information emerged from additional interviews. This rigorous methodology ensured that the findings were comprehensive and reflective of the collective expertise of the participants in school health policymaking. By adhering to these methodological standards, the research sought to enhance the validity and reliability of its conclusions concerning the factors influencing school health policies (Table 1).

Table 1.

Demographic information of the interviewees

	Sex	Age	Educational level	Position	Executive experience in the field of school health	Type of interview
1	Female	55	General practitioner	In charge of school health unit for adolescents and youth	12 years	In person
2	Female	51	Master in healthcare management	Adolescent and school health expert	25 years	In person
3	Female	49	Pediatrician with MPH degree	Head of Adolescent, Youth and School Health Department, Ministry of Health	19 years	In person
4	Female	56	Master in midwifery	Adolescent and school health expert, Adolescent, Youth and School Health Department, Ministry of Health	9 years	In person
5	Male	55	General practitioner with MPH degree	Deputy of Population, Family and School Health Office of the Ministry of Health	19 years	In person
6	Female	51	Social medicine specialist	Faculty member and health Vice Chancellor of University	1 year as a faculty member and 15 years of executive experience	In person
7	Female	48	PhD in educational psychology	Expert in charge of health education planning at the Ministry of Education	20 years	In person
8	Male	43	PhD in health policymaking	Faculty member and head of Health Services Management Research Center	Research experience in the field of school health, 5 years as a faculty member, 3 years of executive experience	Via telephone
9	Male	44	PhD in health policymaking	Policymaking faculty member	Research experience in the field of school health, 7 years as a faculty member	Via telephone
10	Male	58	General practitioner	Deputy advisor of physical education and health at the Ministry of Education and the head of Farhangian Hospital and the executive experience of the director general of the health and wellness office at the Ministry of Education	25 years	Via telephone
11	Female	55	PhD in educational management	Advisor to the general manager of the health and wellness office at the Ministry of Education	25 years	Via telephone
12	Female	48	PhD in management	Vice President of Physical Education and Health of the General Directorate of Education and Head of the Health and Wellness Department at the General Directorate of Education	20 years	Via telephone
13	Female	50	Bachelor in nursing	The deputy principal of the exceptional school, the Head of the Health and Wellness Department at the General Department of Education and the health care provider of exceptional and normal schools	23 years	Via telephone
14	Female	42	Master in midwifery	Responsible for adolescent, youth and school health unit	2 years	Via telephone

Data collection

The data collection tool used in this study was a semi-structured interview developed by the research team (see Table 2). Interviews were conducted both in person (7 interviews) and via telephone (7 interviews). To arrange an interview, participants were contacted by phone or email, and a mutually agreeable time was scheduled. Prior to the face-to-face interviews, participants received a notification form via email or fax to prepare them for the research. At the start of each in person interview, the experts were informed about the study’s objectives and assured of the confidentiality of their responses. Informed consent was obtained from all participants before proceeding. All interviews were recorded with the participants’ knowledge, and note-taking was also employed during the sessions. The interviewing process continued until data saturation was reached. If additional interviews were deemed necessary during the analysis, they were conducted accordingly. Participants had the option to withdraw from the study at any point, and all data related to those who chose to withdraw were removed from the research files. To ensure confidentiality, participants were assigned codes to anonymize their information.

Table 2.

Interview questions

	Questions
1	In your opinion, what are the most important factors influencing the improvement of health policies in Iranian schools?
2	In your opinion, what are the biggest challenges facing school health policies in Iran?
3	How can the health system (Ministry of Health/Universities of Medical Sciences) support the advancement of health policies in Iranian schools?
4	How can the education system (Ministry of Education/Education Organization) contribute to the promotion of health policies in Iranian schools?
5	If we want to leverage the potentials and capacities in sectors outside the health and education systems to achieve school health goals in Iran, what infrastructures and backgrounds (legal requirements, contract terms, resources, etc.) are necessary?
6	In your opinion, what is the best approach to monitor, control, and evaluate the performance of school health policies at different levels?
7	What do you see as the achievements and impacts of school health policies in Iran?
8	Finally, if there are any other topics or issues you would like to discuss, please share them with us.

Data analysis

The data were analyzed using the framework (structural) analysis method through its five steps: familiarization, identifying a conceptual framework, indexing, charting, mapping and interpretation [17]. After conducting the interviews, each session was recorded and subsequently transcribed for detailed analysis. The transcribed interviews were imported into MAXQDA V-10, a qualitative data analysis software. Specific features of MAXQDA V-10 include its code system, text analysis tools, visualization tools, memoing functionality, and export options. Using MAXQDA V-10’s code system, codes were created and assigned to various themes and patterns identified in the transcripts. This process involved labeling segments of text to systematically organize the data. The software’s text analysis tools enabled efficient searching, retrieval, and analysis of coded segments. These tools included: Drag-and-Drop Coding: Facilitated easy and quick assignment of codes. Automatic Coding: Allowed for coding based on specific search terms. Project-Wide Searches: Enabled comprehensive searches across the entire dataset. MAXQDA V-10 also provided various visualization tools to create charts, graphs, and diagrams, helping to illustrate relationships and patterns within the data. Additionally, memos were used to document ideas, insights, and reflections throughout the analysis process, ensuring a thorough and organized approach. The software’s export options allowed us to generate reports and export the analyzed data into formats suitable for further analysis and presentation. To validate the findings, the results were compared with expert opinions and specialist reviews, ensuring the reliability and accuracy of the analysis. Finally, the main components affecting school health were identified as themes and sub-themes. Similar themes and sub-themes were merged where possible. This structured approach and use of advanced software ensured a comprehensive and rigorous analysis of the qualitative data collected.

Trustworthiness of the data collection

Based on Lincoln and Guba criteria [18] four key measures were employed to ensure the trustworthiness of the data collection in this research: credibility, dependability, confirmability, and transferability. These criteria were used to enhance the validity of the study.

Data quality

To ensure credibility and data quality in the selection of key informants and interviewing methods, we chose experts with experience in school health policymaking at Ministry of Health, Ministry of Education, and University of Medical Sciences. We dedicated sufficient time to collect data through face-to-face interviews, as well as telephone interviews for those who could not participate in person. Data integration and thematic content analysis were also conducted.

Generalizability

Data were primarily collected through face-to-face interviews. Telephone interviews were conducted for informants who could not attend in person. To validate the findings, further studies are needed.

Methodological considerations

To ensure dependability, data validity, and reliability, two researchers assessed the robustness of the data analysis. Some participants verified that the research results aligned with their experiences during informant checking. The interview guide was finalized through an initial interview with three experts and was approved by the research team. For confirmability, the researcher thoroughly documented all stages of the research (concepts, variables, data collection, and analysis) to allow others to replicate the work if needed. Regarding transferability and generalizability, the researchers presented the findings precisely and transparently, comparing them with those from other studies.

Future research

To address the challenges of this study, it is recommended to conduct more research in this area. Future studies should consider strategies to overcome participant availability issues and optimize data collection methods to ensure comprehensive and reliable findings.

Results

Overall, 14 school health experts participated in the interviews. Various aspects of the issue were investigated and analyzed, including the identification and analysis of beneficiaries, background factors, policymaking process, content of policies, and effective operational solutions in school health. Table 3 presents the factors influencing the role and performance of health actors.

Table 3.

The role and performance of health actors in schools

Main theme	The role and performance of school health actors
Topics	Inhibiting factors	Facilitating factors
Subtopics	• Officials’ disbelief in the importance of school health. • Absence of a common and unified view towards school health. • Lack of sufficient media participation. • Lack of support from organizations. • Inadequacy of budget allocated from public revenues. • Lack of participation from all organizations. • Poor management. • Conflict of interests between school health trustees. • Incompetence of school principals. • Failure to utilize the capacity of private sectors and NGOs	• Interaction of students’ parents in developing programs. • Seeking assistance from benefactors

Inhibiting factors for school health actors

Based on Table 3, the factors inhibiting the role of school health actors include: officials’ lack of belief in the importance of school health, absence of a common and unified perspective towards school health, insufficient media participation, lack of organizational support, inadequate budget allocation from public revenues, lack of participation from all relevant organizations, poor management, conflicts of interest among school health trustees, incompetence of school principals, and failure to utilize the capacity of private sectors and NGOs. In this regard, one of the experts has asserted:

“The media can be effective, but they often focus on the issue negatively and create more controversy. However, the media should be one of the program’s partners.” (Interview No. 12).

Facilitating factors for school health actors

Students’ parents, as one of the most important factors in school health policies, can play a crucial role in formulating these policies by engaging in macro-planning based on students’ needs. One of the interviewees highlighted this issue:

“Regarding macro-planning, yes, we are interacting with the Parents and Teachers Association through the education department.” (Interview No. 5).

Additionally, benefactors have consistently played a significant role in funding school-related affairs, such as building schools across the country. Regarding school health, interviewees indicated that benefactors have contributed to some extent by providing budgets for various health-oriented programs, such as supplementation initiatives. In this regard, one of the participants said:

“We often rely on benefactors and NGOs to provide supplements, as we lack the necessary funds for students. Benefactors support us in this effort.” (Interview No. 8).

In general, according to the interviewees, the beneficiaries and key stakeholders in school health include the Ministry of Health, Ministry of Education, Municipality Organization, Judicial Power, Legislature, Fire Department, Ministry of Interior, Red Crescent, Natural Resources Organization, Department of Environment, State Welfare Organization of Iran, Imam Khomeini Relief Foundation, Agriculture Jihad, students, students’ parents, school principals, benefactors, non-governmental organizations, and society at large.

Table 4 presents the factors influencing the policymaking process of school health.

Table 4.

Factors influencing the policymaking process of school health

Main theme	Policy making process
Topics	Weaknesses	Strengths
Subtopics	• Failure to pay attention to the internal rules of the Ministry of Education. • Lack of specialization in appointments, • Lack of caregiver surveys. • Absence of a dedicated budget for health in education. • Lack of knowledge among plan implementers about school health rules. • Insufficient expansion of health policies for all teenagers and young people. • Lack of alignment and coordination between different departments. • Lack of coordination between the Ministry of Health and the Ministry of Education. • Absence of need assessments for teenagers and young people. • Failure to formulate laws according to societal needs. • Power imbalances among the units in the two ministries. • Failure to conduct detailed internal audits by schools. • Poor regulations. • Inadequate presence of legislative and executive powers. • Failure to implement health rules. • Failure to use monitoring for correction. • Lack of participation by the Ministry of Education in all school health policies. • Lack of educational hours dedicated to health in schools. • Sporadic and inconsistent plans and projects. • Arbitrary implementation of policies. • Lack of culture-building and health awareness in schools. • Lack of qualitative and accurate approaches in evaluations. • Lack of appropriate monitoring and indicators. • Absence of a national perspective on school health. • Failure to review students’ health needs. • Reduced project credits over time. • Lack of priority at the macro level. • Lack of service leveling. • Lack of participation by all organizations in implementation. • Failure to obtain feedback from organizations. • Lack of human resources. • Irrelevance of health care workers’ fields of study. • Lack of incentives in the system. • Idealistic views in program development. • Lack of required information systems. • Failure to use virtual spaces for educational content. • Poor presence of health in policies. • Improper budget allocation. • Failure to recognize the role of the Department of Adolescent and Youth Health. • Overlapping of plans and projects.	• Providing funding from various organizations. • Achieving consensus in developing indicators. • Collaboratively compiling some plans. • Conducting surveys with students and parents. • Including school health in development programs. • Implementing plans as pilot projects. • Considering international trends in policy formulation. • Conducting studies and field plans for needs assessment. • Using scientific findings in program development. • Conducting surveys with other organizations. • Leveraging successful experiences from other countries and conducting comparative studies. • Localizing programs through universities and provinces. • Using previous performance records in policymaking. • Analyzing beneficiaries in new policies and plans. • Requiring health assessments before school registration and entry.

Weaknesses of the school health policymaking process

Based on Table 4, regarding the weaknesses of the school health policy process, the interviewee stated:

“We have restrictions that are manageable and can be addressed through negotiations and memorandums regarding the numerous issues we’ve faced so far. It’s not as though the Ministry of Health can easily enter schools and conduct their inspections. We have a series of internal rules within the Ministry of Education and Culture.” (Interview No. 13).

Strengths of the school health policymaking process

Regarding the strengths of the policymaking process, the experts highlighted several issues based on Table 4, which are as follows:

“Fortunately, in our country, we have strong laws in both the health and student health fields. For example, the 6th and 5th Development Programs, as well as laws related to allocating a percentage of the production and sale of tobacco products from companies and industries, support these areas.” (Interview No. 5).

Weaknesses in the content of school health policies

Based on Table 5, research experts identified the most significant weaknesses in the content of school health policies as follows:

Table 5.

Factors affecting the content of policies

Main theme	Content of policies
Topics	Weaknesses	Strengths
Subtopics	• Failure to include the three pillars—students, parents, and schools—in all policies. • Multiplicity of projects. • Insufficient health education content. • Separation of physical and mental health in projects and programs. • The optional nature of programs related to School Health Promotion.	• Improving the health of school employees. • Health ambassadors. • Complementary aids. • Pediculosis project. • Weight and Obesity Control project. • Periodic examinations of students. • Health promotion project. • Social Care System for Students project. • National virtual training course to prepare students for challenging times. • Promoting environmental health and school safety. • Education and prevention of communicable and non-communicable diseases. • Empowering employees. • Distribution of food security and healthy snacks. • Education on maturity and personal health. • Preparation of electronic content.

“The weakness is that perhaps only 50% of the policies are implemented in schools because there are so many projects. These projects are communicated to numerous schools, causing them not to take the initiatives seriously and eventually abandon them.” (Interview No. 11).

Strengths in the content of school health policies

Regarding the strengths in the contents of school health policies, one of the experts stated:

“In the past, not much attention was given to the health of school staff. However, there has since been an emphasis on the importance of staff health. Meanwhile, the aspects related to students’ care have progressed significantly.” (Interview No. 4).

Table 6 presents the factors influencing the policymaking process in school health.

Table 6.

Factors affecting school health policymaking

Main theme	Policymaking process
Topics	Weaknesses	Strengths
Subtopics	• Structural problems of schools. • Lack of facilities and infrastructural issues. • Economic sanctions. • Lack of funds. • Failure to consider some needs and problems due to society’s taboos. • Problems of nomadic and rural areas. • Use of political influence in appointments. • Conflict of interests in the implementation of programs due to economic issues. • Need for more training in the slum areas. • Slow pay-off of health programs. • Low acceptance of programs by male students. • Attention to geographical conditions in prioritizing programs.	• Easy acceptance of programs in areas with higher social class. • Paying attention to geographical conditions in prioritizing programs.

Strengths of school health policymaking process

Based on Table 6, the negative aspects of the policymaking process that affect the school health are as follows:

“We face global issues with school infrastructure. Even today, many classrooms have doors that open inward, whereas they should open outward. We need to address our infrastructure problems. Our school lacks facilities to provide healthy food and proper security.” (Interview No. 12).

Weaknesses of school health policymaking process

As shown in Table 6, the research experts highlighted the positive aspects of the policymaking in addition to the weaknesses of school health policymaking:

“Cultural issues should be taken into consideration, as the wealthier students are very receptive to these programs. It may not be necessary to teach them about the etiquette of brushing their teeth.” (Interview No. 11).

Inhibiting factors in school health policymaking

Among the factors preventing the implementation of school health programs, the lack of belief in school health by the authorities was noted by interviewee number 13:

“The most important issue is that the Vice-Chancellor of Health, Physical Activity, Education, and Human Development, who believes in and understands the field of health, can be effective in budget discussions. Another significant inhibiting factor among health actors is that planners and implementers at lower levels lack a common view and alignment on school health issues. This misalignment leads to problems in both policy formulation and program implementation. Without unanimity, achieving school health goals will be difficult.” (Interview No.13).

In the context of the policymaking process, one significant obstacle is the timeliness of the plans. This issue can be attributed to changes in government and a lack of long-term vision in school health policies. Interviewee No. 13 stated:

“All of this is context-specific. For example, several years ago, there was a plan called the “Parents as Doctors” initiative. This plan involved identifying the number of parents who are doctors in each province and utilizing their expertise to educate students. However, this initiative eventually ended.” (Interview No.13).

Another obstacle raised during the interview is the lack of priority at the national level. Due to numerous country-wide issues, including economic problems, student health is not prioritized nationally. This results in improperly formulated plans, inadequate budget allocation, insufficient manpower, and ultimately, the improper implementation of plans. Interviewee number 12 mentioned this issue:

“During an economic recession, the priority shifts to meeting the essential needs of the people, such as providing food. Given the current economic situation, school health is not the top priority. It’s similar to wartime conditions: the implementation of health programs, like the iron assistance plan, is not prioritized. The primary concern is fulfilling basic necessities. Therefore, the recruitment of healthcare workers has not occurred due to budget constraints.” (Interview No.12).

One of the key weaknesses related to the content of health policies, which disrupts program coherence, is the failure to include the three aspects of students, parents, and schools in all policies. In this regard, Interviewee number 11 stated:

“The weakness is that perhaps only 50% of the plans are implemented in schools because there are so many plans. These plans are communicated to numerous schools, causing them not to take the initiatives seriously and eventually abandon them.” (Interview No.11).

In policymaking, one important aspect of school health is environmental health and the structure of the hospital, which must be approved for safety and health standards. Due to the dilapidated condition of many schools in Iran, they lack up-to-date and safe standards, affecting the hygiene of advanced schools. Many participants in the research have mentioned this issue:

“We have problems with school infrastructure worldwide. Even now, many classroom doors open inward when they should open outward. For instance, if the doors during the Shinabad fire had opened outward, everyone could have exited quickly. Our school lacks proper security.” (Interview No. 12).

To implement any program, it is necessary to secure funds from the government and responsible organizations. According to the research participants, the main obstacle in implementing school health programs is the lack of funds and credit from the government and trustee organizations. Interviewee number one mentioned:

“I think the budgets are too small. Health initiatives should have sufficient funding, so that if certain factors cannot be addressed in one area, they can be financially supported elsewhere to advance their goals.” (Interview No.1).

One important factor causing delayed feedback and a lack of tangible short-term results in health programs is their long-term nature. Consequently, expecting short-term outcomes is unrealistic. Interviewee number two stated:

“There is a problem with the health of schools because it focuses on the long term, making feedback tiresome over time. When addressing malnutrition, it takes a long time for a full recovery. In general, achieving our goals for school health is a primary concern for society. Conversely, politics operates from the top down, while benefits move from the bottom up.” (Interview No.2).

Figure 1 shows the main inhibiting factors in school health policymaking.

Fig. 1.

The Main Obstacles of School Health Policymaking

Table 7 indicates the best strategies and contributing factors for improving school health policymaking.

Table 7.

Strategies and contributing factors for improving school health policymaking

Main theme	Suggestions
Topics	Policy content	Policymaking process	Role and performance of school health actors
Subtopics	• Definition of school health lesson. • Implementation of policies in the form of a package. • Teaching skills to students in the field of health. • Informing and educating parents. • Considering age and cultural differences. • Integration of policies and programs.	• Culture building in the field of health. • Doing more research. • Paying due attention to infrastructure. • Recruitment and training of human resources. • Allocation of educational hours for health. • Investment and financing. • Continuous education in all levels of education. • Establishing a national committee to develop a policy. • Prioritizing the needs of teenagers and young people. • Forming an independent decision-making unit. • Meritocracy in the appointment of managers. • Relationships between the information systems of the two ministries in charge. • Presence of effective evaluation systems. • Development of appropriate indicators.	• Direct communication between the Health Office and the Minister of Education. • Participation of organs and organizations. • Prioritizing the health of schools in the macro policies of the country. • Officials’ belief in the health of schools. • The school officials’ being demanding.

Policy content

Based on Table 7, the strategies for improving the content of school health policy, from the experts’ point of view, include: defining a school health curriculum, implementing policies in a comprehensive package, teaching health skills to students, informing and educating parents, considering age and cultural differences, and integrating policies and programs. In this regard, Interviewee number seven stated:

“In the field of health, a school health curriculum should be defined. Health educators need to have a dedicated lesson plan. They should enter the classroom and teach students essential skills. Currently, this is a major weakness.” (Interview No. 7).

Policymaking process

Additionally, the experts highlighted several issues regarding the promotion of the policymaking process, as shown in Table 7.

“In the field of health, it should be a priority for everyone, from the entire country to the governor general, the governor, the minister, and even the president.” (Interview No. 13).

Role and performance of school health actors

The solutions proposed by experts to enhance the role and performance of school health actors include: direct communication between the Health Office and the Ministery of Education, participation from various organizations, prioritizing school health in national policies, officials’ belief in the importance of school health, and proactive demands from school officials. In this regard, the experts have stated:

“I believe the Health Office should be directly supervised by the Ministery of Education. To achieve meaningful change, it needs to fall under the Ministery of Education’s direct supervision.”(Interview No. 8).

Discussion

This study aimed to identify factors influencing school health policies and offer solutions for their improvement through interviews with experts. The findings highlighted several key positive and negative factors affecting school health policies, including the role of stakeholders, policy content, policy context, and the policy-making process. These insights align with previous research but also introduce new perspectives that deserve further consideration.

One of the critical findings in this study was the lack of prioritization of school health by higher-level managers. This disinterest at the upper management level has been shown to hinder the adoption of school health policies, as policy priorities often reflect the views of those in power. This resonates with findings from Inchley et al. [19] who identified a similar pattern in the United Kingdom, where policy support for health promotion in schools was often superficial, largely due to leadership’s lack of commitment. However, the current study expands on this by underscoring the importance of alignment between planners and implementers at the lower levels, which was less emphasized in earlier studies. Specifically, disconnect between these groups leads to fragmented policy implementation, creating barriers to effective health promotion. In this context, other researchers have noted that a significant barrier is the insufficient prioritization by senior management, which impedes the adoption and implementation of policies [20, 21]. Inconsistencies in policy awareness and translation at the district level, combined with insufficient human resources and inadequate communication from national leadership, further hinder effective implementation [21]. The misalignment between organizational priorities and system-level policies adversely affects the implementation and sustainability of health interventions in schools. To tackle these challenges, it’s recommended to adopt multi-level implementation strategies and focus more on enhancing organizational capacity [22].

In addition, the study highlights the crucial role of media in building public awareness and supporting school health programs. While the role of media in health promotion has been acknowledged in various contexts [15, 23], the current study stresses its importance for shaping societal attitudes toward school health. This highlights the necessity for more focused media strategies to enhance community engagement and support for health policies in schools. It might be beneficial to draw inspiration from countries like Finland, where media has been effectively utilized for health promotion [24].

This research also emphasizes the necessity for cooperation between the Ministries of Health and Education, an issue that has been noted as a significant barrier in many countries. Studies by Azimi [23] and Jourdan et al. [25] also identified the lack of inter-ministerial coordination as an obstacle to effective school health programs. The current study adds depth to this by suggesting that the financial resources allocated to school health programs are insufficient to meet the demands of such comprehensive initiatives. This echoes findings from Mclsaac et al. [26], who found that inadequate funding was a consistent challenge in implementing health-promoting schools, particularly in low-income areas.

Furthermore, the lack of sufficient infrastructure, particularly in underprivileged regions, is another shared challenge. In this context, a research indicates that inadequate school infrastructure is linked to worse health outcomes and reduced academic performance in children with asthma [27]. Implementing Coordinated School Health Programs (CSHPs) can enhance school health services and infrastructure, which may result in improved academic performance and physical fitness among students [28]. The findings of this study suggest a phased approach: beginning with pilot programs before moving to full-scale implementation to ensure feasibility and secure the necessary resources. This approach, supported by Jourdan et al. [25], has proven effective in countries like Canada, where pilot projects allow for adaptive strategies in health education.

A key factor in the successful implementation of school health policies is the availability of competent human resources. Our study identifies the lack of skilled professionals as a major barrier to successful policy implementation. This finding is consistent with recent research, such as Hoveyzi et al. [15] and Mclsaac et al. [26], who argue that continuous professional development and training are crucial for school health program success. In this regard, the current study calls for ongoing capacity building for both health experts and school principals to enhance their competencies in managing health programs.

Moreover, the study underscores the need for a clear, long-term vision in health policies. The observed inconsistency in health program implementation due to governmental changes is a notable challenge that has been acknowledged in multiple contexts. Asadi et al. [29] highlighted that essential elements of comprehensive school health policies encompass nutrition, environmental health, community collaboration, and health services. However, common challenges such as limited resources, inadequate training, and poor referral service capacity can result in inequitable access to and quality of school health services. However, the implementation of policies often faces inconsistencies due to changes in government and a lack of prioritization from district and facility managers. Common challenges include limited resources, inadequate training, and poor referral service capacity, which result in inequitable access to and quality of school health services [30]. Jourdan et al. [25] highlighted that political instability often disrupts continuity in health promotion efforts, a point that is reiterated in our findings. Thus, the suggestion to institutionalize health programs through legal frameworks and ensure their continuity regardless of political changes is both timely and relevant.

Another important finding was the lack of involvement of parents and communities in school health policies. This issue is not unique to the context of this study. As noted by Hoveyzi et al. [15], and in line with the experiences of Azimi [23], the absence of parental and community engagement in health programs weakens their impact. The study calls for stronger mechanisms to involve parents and communities, which is supported by international research that stresses the importance of a whole-community approach to health promotion. In New Zealand, involving parents in school health education has proven to greatly enhance the effectiveness of these programs [31].

Finally, the study suggests that drawing from successful international models could provide useful policy insights. The comparison with other countries’ school health systems reveals that evidence-based practices and the integration of technology play key roles in advancing school health policies. For example, countries like Sweden and the Netherlands have integrated digital health education tools into school curricula with great success [26]. This approach, supported by recent studies, demonstrates the potential of technology to facilitate continuous monitoring and evaluation of health policies in schools. The current study’s recommendation for the use of information systems and technology to track policy implementation is consistent with global trends in education and public health.

While this study provides valuable insights into the factors influencing school health policies and strategies for improvement, several limitations should be acknowledged. First, the qualitative design and purposive sampling limit the generalizability of the findings. Second, data collection relied primarily on self-reported interviews, which may be influenced by social desirability bias or personal perspectives that do not fully reflect institutional or systemic realities. The absence of triangulation with other data sources (e.g., policy documents, direct observations, or quantitative data) may limit the comprehensiveness of the analysis. Third, some interviews were conducted via telephone rather than in-person, which may have affected rapport building and the depth of responses, especially when discussing sensitive or political topics related to inter-ministerial collaboration and leadership engagement. Additionally, contextual factors unique to Iran, such as political structures, centralized decision-making processes, and resource constraints, may limit the transferability of findings to other settings. Though parallels with other countries were noted, further cross-national comparative research is needed. Lastly, while framework analysis provided a structured method for organizing and interpreting the data, there remains a degree of subjectivity in theme identification and interpretation, which could influence the conclusions drawn. Future studies would benefit from a mixed-methods approach, broader stakeholder inclusion—particularly parents and students—and longitudinal designs to evaluate the long-term impact of proposed policy changes.

Conclusion

This study aimed to identify the factors influencing school health policies and propose strategies for their improvement. The findings reveal that several key dimensions such as the roles of stakeholders, policy content, background factors, and the policy-making process must be addressed through targeted solutions. To improve school health policies, it is essential to align strategies with students’ needs, foster intra-organizational and inter-departmental cooperation, secure financial resources, enhance infrastructure, and prioritize health at the macro level. Utilizing the latest scientific evidence is crucial in formulating and implementing effective policies. Recommendations for enhancing stakeholder engagement include developing a shared vision for school health at all levels of government and school management. Additional strategies include leveraging mass media and digital platforms to promote school health, improving coordination between the Ministries of Health and Education, ensuring adequate financial and human resources, and implementing long-term, sustainable health programs. Furthermore, enhancing community and parental involvement, integrating technology for monitoring and evaluation, addressing adolescent health needs, and strengthening school health evaluation mechanisms are vital steps to ensuring the success and sustainability of school health policies.

Authors’ contributions

Conception and design: Z.A, A.AT; Data collection: Z.A; Analysis and interpretation: Z.A, A.AT, A.AH, H.P; Draft manuscript preparation: Z.A, A.AT, A.AH, H.P. All authors reviewed the results and approved the final version of the manuscript.

Funding

This research was supported by a grant (code 1400-3-37-22074) from the Vice-Chancellor for Research at Iran University of Medical Sciences.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study is part of a doctoral thesis titled “Analysis of Iran’s School Health Policies and the Development of a Model,” which was approved by the Research and Ethics Committee of Iran University of Medical Sciences (IR.IUMS.REC.1400.832). Informed consent was obtained from all participants involved in the study. The research was conducted in compliance with the ethical standards outlined in the 1964 Declaration of Helsinki and its subsequent amendments, as well as other relevant ethical guidelines.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.