There were important differences by facilitation level in how well school teams followed CDC instructions for completing the SHI. In the LF schools, staff tended not to follow the instructions provided in the SHI manual. One school in the LF group distributed the SHI to staff and had them fill it out individually like a survey rather than complete it as a team. In another school, the SHI coordinator discussed the SHI with staff members individually, tabulated results, and came up with an average score. When asked about the SHI team structure, one participant from an LF school said, "Well, quite frankly, until today, I didn't quite realize we were part of the team." In contrast, MF and HF schools more consistently followed the instructions and worked as a team to complete the SHI, involving people from across the school community and, to some degree, the local community. They discussed the SHI during group meetings, then followed up with additional meetings to develop goals and action plans. In the MF and HF groups, decisions were made through consensus on scoring the SHI assessment and on goals and action plans.

The MF group completed all of the SHI modules in one long meeting led by an outside facilitator, and then the team continued to meet monthly without the facilitator to discuss the team's action plan. Two staff members took on the role of team leaders and coordinated the monthly meetings and activities. The outside facilitator for the MF group, who worked on the district level, did not attend monthly team meetings but did provide guidance and technical assistance to the team as it worked on its action items. The two schools in the HF group completed three modules of the SHI at a series of monthly meetings led by the outside facilitator, and then the teams continued to meet monthly with the facilitator to work on their action plans.

Members of the MF and HF groups perceived the facilitator as having a motivating presence in meetings, describing that they felt the facilitator kept the team focused, helped it achieve consensus on decisions, and guided it in following through with identified action items. A staff member in the HF group commented on how the team's experience might have been different had they not had a facilitator: "I think it probably would have been much more frustrating to try to get some policies or just get some consensus. I think it would have been more difficult. She [the facilitator] kind of keeps us on track."

Participants from all three groups perceived that support from the school administration was essential. They described the following ways that they felt school administrators could support the efforts of health promotion teams: 1) ensure that staff have protected time to meet as a team; 2) participate in the team's meetings; and 3) authorize implementation of action plans. Before starting the SHI self-assessment, teams in both the MF and HF groups garnered support from the school administrators. In the MF group, the principal of the middle school participated in the team meetings. In the HF group, before initiating work on the SHI, the facilitator met with the school principals and staff and obtained a letter of support from the superintendent and agreement from the principals to allow the team to implement its recommendations. The facilitator from the HF group commented, "You absolutely need the approval, the blessing, of the principal to make this work." In three of the four LF schools, full support from the school principal was not obtained before embarking on the SHI self-assessment; the principals did not participate in team meetings nor did they agree to implement recommendations from the team.

During the follow-up year, the three groups differed in their reliance on teams and teamwork. In two LF schools, staff occasionally met in pairs or small groups to discuss the SHI results and the schools' health promotion needs, but none of the four LF schools held regular team meetings. In addition, LF schools did not develop and document action plans or work as a team toward defined goals for health promotion. 

In the MF group, participants met monthly without the facilitator, created an action plan, and worked toward goals. Two staff members continued in the role of team leader, and the outside facilitator provided guidance and technical assistance as needed. In the HF schools, the teams continued to meet monthly with the outside facilitator. Using what they described as consensus decision making, they identified goals and an action plan, focusing on a few priority issues, and worked as a team toward implementing those changes. A participant from a community agency in the HF group commented:

The kinds of activities and goals emerging from schools in each of the facilitation levels appeared to differ in two potentially important ways: task complexity and degree of collaboration used to achieve goals. Participants in LF schools described a variety of changes achieved by Time 2, most of which involved effort by one or two people. Changes mentioned included assigning a substitute teacher to teach PE classes that the regular PE teacher could not fit into her schedule, ordering exercise videotapes for PE classes and classroom resources on nutrition and physical activity, and allowing students access to the gym before and after school. With her school district facing drastic budget cuts, one PE teacher in the LF group considered the fact that PE classes had not been completely eliminated from the curriculum to be a positive result of their having completed the SHI assessment, which she believed had sensitized administrators to the need for PE. She also intimated that she doubted policy improvement in PE could be expected in her school:

In the MF group, activities achieved by the team in the year following completion of the SHI required substantial changes in school food service operations, including reducing the frequency that french fries were served, rearranging the lunch line so students passed by vegetables first, installing milk machines, and substituting baked for fried foods. In addition, the MF group planned and implemented a student health fair and staff wellness day and established a subsidized health club membership for staff. 

By the time of the second wave of interviews, however, several changes instituted by the school district, including the departure of a key advocate in the administration of the SHI team's work, had recently occurred. Members of the MF group felt these changes led the team to become less active. A staff member from the MF group explained:

In the HF group, the two schools' teams shared the same outside facilitator and began working on initiatives in similar ways. However, in one of the HF schools, near the end of the year, the district slated the school for closure, so the team stopped working on the planned changes. The other HF school differed from all the other schools in the study in that its team decided to focus on a single health issue that team members considered both important for student health and realistic for the team to address within the school year, given limited resources and time. In this school, the team chose to promote student hand washing before meals and snacks. Ensuring that students can wash their hands before meals and snacks is included as a recommendation in the school environment module of the SHI. Coordinating hand washing by hundreds of students every day required significant planning and collaboration across different sectors of the school community. The team planned this new initiative, gained approval of the school superintendent, developed an evaluation plan, acquired and installed hand-sanitizer dispensers, trained teachers on the new policy, and implemented the policy schoolwide to ensure that students washed their hands before eating snacks and meals. A participant from the school observed, "The fact that the team worked as a team and included everybody else, I think really helped move this thing along quickly."

Participants in all three groups described insufficient funding for staff, sale of nonnutritious snack food to fund operating costs for school food services, and lack of physical activity space and equipment as barriers to health-promoting change. School staff from all three groups also reported that health programs and policies were at times seen by administrators as conflicting with student academic achievement. One teacher from an LF school described state and federal programs that she felt presented obstacles to health promotion efforts: "Well, unfortunately . . . right now their priority is the [state standardized testing] and the No Child Will Be Left Behind. . . and unfortunately, maybe as a result, other issues are left behind."

Participants in the MF and HF groups described three central roles played by outside facilitators:

1. Administration buy-in: Facilitators helped garner support from the administration before the SHI assessment was begun. They secured commitment from the administration to allow the team to meet regularly and to implement initiatives decided upon by the team.

2. Team structure: Facilitators guided schools toward using a team structure, as recommended by CDC, to complete the SHI assessment and implement initiatives. Facilitators supported team structure by ensuring that 1) key stakeholders from across the school community and, to some degree, the local community were included on the team; 2) team meetings were held regularly for continued contact and communication among team members; and 3) team meetings were facilitated with an emphasis on consensus building and management of group tensions and conflict.

3. Team sustainability: Facilitators helped teams become sustainable by maintaining team motivation and team cohesion through coaching and focus on feasible tasks to foster a sense of concrete gains and accomplishments.

One participant from a community agency in the HF group emphasized the importance of the facilitator:

She saw the SHI as an important tool but not sufficient to effect change in schools: "A tool alone is not effective," she explained. "It's got to go in there with an advocate, with somebody to help it, help implement that tool."