PONE-D-25-54611Key functions for the transferability of a French school-based health promotion intervention: application of the FIC modelPLOS One

Dear Dr. Riera-Navarro,

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This work was funded by the French National Cancer Institute (INCa-16818), the French Institute for Public Health Research (IReSP-AAP-2021-273199) as part of the 2021 Research Call on Health-Promoting Services, Interventions, and Policies (supported by CNAM, DGS, Inserm, MILDECA, and Santé publique France); the French Interministerial Mission for Combating Drugs and Addictive Behaviors (MILDECA); and the Auvergne-Rhône-Alpes Regional Health Agency, with funding allocated to Véronique Régnier and Franck Chauvin (University Jean Monnet Saint-Etienne, Health, Systemic, Process Research Unit 4129). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The SO-RISP research network, with support from the French National Cancer Institute, received INCa-Cancéropôle GSO support. This research was funded by IReSP as part of the call for structuring actions for research on uses and addictions to psychoactive substances 2021 (IRESP-AAPSPA2021-V1-06).

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Additional Editor Comments :

Overall, the study is seen to make a useful contribution by the reviewers, but important clarifications and refinements are needed to strengthen its scientific rigor and positioning.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: The manuscript makes a valuable contribution to the field of PHIR by addressing the challenge of supporting the transferability of interventions, which requires identifying both their invariant components and their contextual adaptations. In this respect, the FIC approach constitutes a robust method for describing complex school-based interventions.

I believe this article could make a meaningful contribution to PLOS One, and I therefore recommend it for publication, subject to minor revisions : a number of comments are offered below, suggesting adjustments that could help clarify the theoretical positioning, methodological choices, and discussion. The questions and suggestions are detailed for each section :

Introduction

- Regarding the IPS indicator, given that the journal has an international readership that may not be familiar with this measure (reference 4 is in French), it might be helpful to further specify what this indicator captures and to indicate the range of values it can take.

- The Alliance intervention was expanded in Phase 2: was there an evaluation of the effectiveness of the intervention in Phase 1 that justified this scale-up?

- In relation to the dialogue with existing conceptual frameworks, you note that “Various models and approaches have been developed to support the assessment of transferability.” These models are only briefly mentioned: it would be useful to clarify how the FIC approach differs from them and/or why it may be more relevant than other methodologies or frameworks for evaluating implementation and fidelity described in the international literature.

- You state that “Transferability involves not only replicating implementation (applicability) but also achieving similar outcomes in new contexts.” It would be helpful to clarify whether the FIC evaluates the replication of implementation and/or outcomes (effectiveness). A similar overlap appears later in the discussion between implementation success and intervention success.

- Finally, why is the potential to assess impacts on equity and social health inequalities—something the FIC method seems well suited to address—not mentioned? This issue is central in PHIR and in discussions of the transferability of complex interventions, yet it does not appear to have been considered in the analysis of the Alliance intervention.

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Methods

- The role of Phase 2 data would benefit from being more clearly distinguished (for instance, by specifying whether certain functions emerge only in Phase 2, whether Phase 2 confirms or refines functions retrospectively identified from Phase 1, or whether the only distinction lies between theoretical forms in Phase 1 and observed forms in Phase 2).

- You state that “The guide was developed based on the literature on factors influencing the implementation of school-based health promotion interventions and the RE-AIM framework.” It is somewhat surprising that this theoretical framework was used in the study but is neither mentioned nor described in the theoretical section. Clarifying how RE-AIM contributes to the FIC approach, and how it informed the interview guide in comparison with a “classic” FIC interview grid (if such a generic grid exists), would be helpful. Moreover, if the RE-AIM framework was used beyond the construction of thematic entries in the interview guide, did you also use quantitative indicators to assess implementation and transferability? If so, which ones?

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Data Analysis

- You indicate that “model construction was informed not only by qualitative data but also by internal project documentation and feedback from health promotion consultants.” Could you briefly specify what these additional sources contributed? For instance, did they provide new insights, or help triangulate findings from the main qualitative data collection?

- The role of the research team in constructing the key functions would also benefit from greater critical reflexivity, particularly with regard to the risk of circularity (i.e., what “works” being what is already implicitly valued).

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Results and Discussion

- The description of key functions and their theoretical and observed forms is clear and well supported by Figure 1, which provides a useful synthesis of the FIC results. However, additional contextual elements (identified barriers and facilitators) might be expected in the results and discussion, as these are clearly shown in the figure but only minimally exploited or discussed in the text.

- The discussion is rich, well-referenced, and well articulated with the literature, enabling meaningful comparisons. It successfully positions the FIC method as a tool for in-depth intervention description and for supporting transferability. However, you focus on certain functions as being critical for intervention effectiveness: it would be useful to clarify whether these key functions contribute to implementation success, intervention effectiveness, or both. If relevant, reporting elements of Alliance’s effectiveness outcomes could help support this argument.

- The discussion could also, where relevant, integrate a comparison of contexts (particularly institutional contexts) in relation to the interventions and the literature mobilized around the key functions of Alliance. In this respect, the specificity of the French educational context could be made more explicit for non-French-speaking readers.

- The perspective on social health inequalities is introduced at the end of the manuscript but would benefit from being more explicitly connected to the study and introduced earlier, including a more timely justification for why this analytical angle was not taken.

- Finally, either in the discussion or the theoretical section, the positioning of the FIC in relation to more prescriptive transferability tools (such as ASTAIRE) is clear and helps to highlight its added value as a reflective framework. However, given the journal’s international readership, it might be useful to briefly discuss how the FIC method could be articulated with other implementation analysis frameworks (e.g., CFIR, PRISM, or the Implementation Research Logic Model), in order to further situate its contribution within the international field.

Thank you for the quality of your work and for this rigorous and insightful contribution.

Reviewer #2: This manuscript addresses a highly relevant and timely issue in population health intervention research: the transferability of complex school-based health promotion interventions. The authors apply the FIC (Functions–Implementation–Context) model to identify key functions underlying the “Alliance for Health” intervention and to distinguish these from adaptable forms across contexts.

The paper is well written, methodologically transparent, and grounded in a solid conceptual and theoretical framework. It provides a detailed and thoughtful description of the intervention and its implementation processes over time. However, the manuscript remains primarily descriptive and conceptual, and several limitations reduce its analytical depth and the strength of its claims regarding transferability.

Overall, the study makes a useful contribution, but important clarifications and refinements are needed to strengthen its scientific rigor and positioning.

Major comments

1. While the manuscript repeatedly refers to transferability and comparable outcomes, the study does not empirically demonstrate that the identified key functions are associated with comparable effects across contexts. The analysis essentially identifies and formalizes key functions a posteriori, based on stakeholders’ accounts and internal project documentation.

As such, the contribution should be framed more clearly as a conceptual and organizational analysis of implementation processes, rather than an empirical assessment of transferability in terms of outcomes.

The authors are encouraged to:

- clarify explicitly that this work does not test causal relationships between key functions and effectiveness;

- moderate statements suggesting that the identified functions ensure or optimize transferability;

rephrase conclusions to emphasize guidance for future implementation rather than evidence of successful transfer.

2. Key functions are co-constructed by researchers, project leaders, and health promotion consultants who were directly involved in the design and implementation of the intervention. While this participatory approach is coherent with the FIC model, it raises a risk of circular reasoning, whereby elements that enabled the intervention to function are retrospectively defined as “key functions”.

The manuscript would benefit from a stronger critical discussion of this limitation, for example:

- Which elements were debated as potentially non-essential?

- Were there functions that varied substantially without jeopardizing implementation?

- How were disagreements resolved during the consensus process?

Clarifying these points would strengthen the analytical robustness of the model construction.

3. The qualitative sample is diverse in institutional terms, but several key perspectives are missing or underrepresented:

- pupils (final beneficiaries),

- teachers other than school directors,

- municipal after-school care staff.

Although the FIC approach traditionally prioritizes implementers and decision-makers, the absence of these voices limits the understanding of acceptability, feasibility, and perceived relevance of the intervention at the operational level. This should be more explicitly acknowledged as a limitation when discussing the generalizability and transferability of the findings.

4. Many key functions (e.g., institutional support, statutory training time, role of rectorates and parliamentarians) are deeply embedded in the French educational and administrative system. This raises questions about: the extent to which these functions are transferable beyond similar national or institutional contexts; which functions are context-specific versus potentially context-agnostic.

The discussion would benefit from a clearer distinction between: functions that are likely to be transferable only within comparable governance systems, and those that may be relevant across different educational or national contexts.

5. Although the study focuses on implementation rather than effectiveness, the repeated reference to “comparable outcomes” creates an expectation that outcomes will at least be discussed in relation to key functions. Currently, outcomes are largely absent from the analysis.

Even a brief, qualitative reflection linking key functions to previously reported results from phase 1 would help align the manuscript’s claims with its empirical content.

6. In the discussion section, the authors could briefly mention how their FIC-based approach complements other French school-based interventions, such as Explo’Santé, which mainly report qualitative outcomes (e.g., changes in psychosocial skills) rather than implementation mechanisms. This would help situate the added value of the present work.

Minor comments

7. The manuscript is relatively long and occasionally repetitive, particularly in the Results and Discussion sections. Some descriptions of key functions could be condensed without loss of clarity.

8. Figure 1 is conceptually informative but difficult to read in its current form (dense content, small font). Improving readability would enhance its usefulness.

9. The distinction between “key functions” and “forms” is central to the paper but could be summarized more succinctly in the Discussion for readers less familiar with the FIC model.

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Reviewer #1: Yes:Marie Cholley-Gomez

Reviewer #2: No

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Key functions for the transferability of a French school-based health promotion intervention

PONE-D-25-54611R1

Dear Dr. Riera-Navarro,

Thank you for your detailed revisions. The manuscript and accompanying response document now fully address the concerns raised by the reviewers and the journal. We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Tahir Turk, PhD

Academic Editor

PLOS One