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Table 2 Refined program theory explaining how factors at different contextual levels may trigger mechanisms that influence staff’s responsibility, motivation and confidence for STP enforcement

From: Understanding school staff members’ enforcement of school tobacco policies to achieve tobacco-free school: a realist review

  Factors at different contextual levels Mechanism Outcome
CMO1 • Individual
Staff’s professional identity and values, e.g. health promotion vs academic education
Staff experience STPs part of the school staff’s professional role and duties Responsibility for STP enforcement
• Interpersonal
Staff’s perceptions on the influence of enforcement to staff-student relationships
• School
Existing workload and the significance of tobacco issue in school
• Implementation components
Anchoring and communicating STP, including staff abstinence from smoking during school hours, as part of the school’s core tasks and all staff’s role and duties through written policies and senior management’s engagement; come up with enforcement practices that do not threaten staff-student relationships
• National
Legislation on STP and on tobacco in wider environment, e.g. ban on smoking in public places
CMO2 • Individual
Staff’s perceptions on schools general ability to influence student smoking
Student’s characteristics (e.g. nicotine addiction)
Staff perceive that their contribution is leading to positive outcomes Motivation for STP enforcement
• Interpersonal
Other staff members’ participation to the enforcement
• Implementation components
Coming up with strategies to tackle enforcement problems (e.g. smoking relocation that increase visibility, non-effective enforcement practices for students with nicotine addiction) e.g. to avert inconsistent enforcement among staff, communicating staff about the progress achieved with STP
• National
Conformity in tobacco norms and aims between school and wider society (i.e. back up for STP)
CMO3 • Individual
Staff member’s own smoking status
Student’s characteristics (e.g. physical or verbal aggression)
Staff feel that they are able to deal with students’ responses Confidence for STP enforcement
• Interpersonal
Staff’s familiarity with the student
• Implementation components
Communicating all staff’s authority for STP enforcement and strengthening staff members’ skills to enforce with difficult or unfamiliar students
• National
Legislation on STP and on tobacco in wider environment, e.g. ban on smoking in public places