Introduction

The health crisis and economic expenditure caused by sedentary behavior (SB) and physical inactivity have garnered widespread attention worldwide1. Physical inactivity represents the fourth leading cause of mortality worldwide. It and SB can lead to a number of health problems, including chronic disease, obesity, and type 2 diabetes1,2. To address these risks, various versions of physical activity and sedentary behavior guidelines published by WHO or local governments recommend that individuals move more and sit less3. These guidelines also emphasize meeting at least the minimum recommended levels of physical activity. However, some researchers have argued that these standards may no longer be sufficient under current health conditions1. Furthermore, Santos (2023)4revealed that the annual global economic losses resulting from inadequate physical activity amount to approximately 47.6 billion US dollars.

Addressing such public health concerns requires strategic health communication. Health communication plays a vital role in promoting physical activity and reducing sedentary behavior, serving as an indispensable instrument in both health education and health promotion. However, despite decades of research on physical activity promotion, policy planning, infrastructure, and health communication efforts remain underdeveloped5. Kohl (2012)5 further identified health communication as a critical yet often overlooked component in this area. Nevertheless, in the current field of health communication and health promotion, there remains a paucity of research focusing specifically on physical activity and sedentary behavior. Moreover, given the interdisciplinary nature of health communication, the development of such competence is inevitably influenced by multiple contextual and individual factors.

As defined by Rogers, health communication is any form of human interaction that pertains to health-related content6. Extensive research has been conducted in this field, contributing to the development of effective strategies and practices that improve public health outcomes. Existing studies primarily focus on two key elements: health communication receivers and health communication senders. Research on receivers often targets specific populations—such as adolescents7, older adults8, or minority ethnic groups9—to identify their unique communication needs and challenges, thereby informing tailored health communication strategies.

In contrast, research on health communication senders typically examines healthcare professionals and institutions responsible for delivering health information. For instance, Lawati (2018)10 conducted a systematic review on health promotion in primary healthcare, with a focus on the health communication strategies and practices employed by healthcare senders and relatable organizations. Similarly, Javier (2018)11 explored communication-based strategies used in clinic- and community-based HIV prevention interventions among African American women, illustrating how sender-oriented approaches can enhance health outcomes within specific social contexts.

Except for research focusing on health communication receivers and senders, theory-oriented studies also represent an important area of inquiry in this field. Haardörfer (2019)12 emphasized the significance of theory-driven and data-informed analysis in social science research, highlighting the importance of introducing theoretical priorities as the foundation of inquiry. Among the theories frequently applied in health education and health promotion, Ecological Systems Theory (EST) has been particularly influential. Wold (2018)13 reviewed three decades of research utilizing the social-ecological model for health promotion and identified the lack of interdisciplinary collaboration and systems thinking as major barriers to progress. Stokols (1996)14 translated Social Ecological Theory into practical guidelines aimed at advancing community health promotion.

Although existing research has provided valuable guidance on the methodology of health communication, the research objectives in the field primarily revolve around healthcare professional in medical setting, such as doctors or nurses, with limited attention given to a specific group who has expertise in promoting physical activity scientifically: PE teachers. Given the interdisciplinary background of health communication, it should span across more relevant disciplines and groups. PE teacher plays a significant role in school health communication and school setting is an essential component in the comprehensive health system. These teachers undergo pre-service education programs and receive relevant in-service training such as sports health science, exercise physiology, and sports anatomy15. In comparison to medical professionals, PE teachers possess specialized knowledge in the subfield of sport health communication. As active participants in both physical education and health communication, PE teachers hold the potential to nurture a nationwide culture of active healthy lifestyle, addressing prevalent health concerns like increasing rates of public sedentary behavior.

In this regard, enhancing PE teachers’ competence in health communication offers a practical and cost-effective means to promote public health and reduce health inequities. While not a universal remedy, school-based health communication led by PE teachers capitalizes on existing educational structures, yielding high efficiency under limited health budgets16,17. Embedded within daily teaching, it ensures sustained exposure, behavioural reinforcement, and strong external validity, as educators in school settings are uniquely positioned to influence students through regular, trust-based interactions18. By integrating health communication into PE practice, this approach bridges the gap between health knowledge and behaviour, advancing both equity and efficiency in national and global health promotion. Moreover, the cost-effectiveness and scalability of communication interventions have been widely recognized in the literature16.

Although certain aspects of health communication research within the field of PE teachers have been explored—such as teachers’ perceptions of digital communication via social media19, the definition and theoretical model of sport health communication15, and participation in health communication volunteering programs20 —gaps remain. Martínez-Rico et al. (2021)21 surveyed in-service secondary PE teachers and reported high self-confidence in operating hardware, but significantly lower confidence in designing online collaborative tasks or using networks to foster pupils’ health-oriented inquiry, indicating that health communication functions remain peripheral to their digital practice. Wallace, Scanlon and Calderón (2023)22 showed that when teachers did share fitness videos or performance clips, students valued the clarity of the health cues but stressed that one-way posting was insufficient; they expected dialogue and contextual follow-up that most teachers felt unprepared to provide. However, clarification on the factors influencing the development of teachers’ health communication competence—and verification of whether these factors genuinely impact their proficiency—remain unclear.

Against this backdrop, the primary goal of this study is to investigate the factors contributing to the development of health communication competence (HCC) in PE teachers. Three central questions guide this exploration:

  • RQ1: How do PE teachers perceive and experience the factors that shape their health communication competence?

  • RQ2: To what extent do these factors genuinely contribute to the development of health communication competence in PE teachers, and which factors exhibit varying degrees of influence?

  • RQ3: What are the characteristics and mechanisms of PE teachers’ health communication competencies when they are formed? Do these align with the EST theory?

By addressing these questions, we used EST as our theoretical foundation and used focus group and individual interview as the research method to firstly explore and form the factors that influence the formation of HCC of PE teachers. Secondly, a questionnaire was designed based on the interview results and the theoretical model and research hypothesis were formed, which were combined with EST. Finally, a survey was conducted of 394 PE teachers, and the structural equation model method was employed to verify the hypotheses and to ascertain whether the formation mechanism of PE teachers’ HCC aligns with the EST theory. This research will provide valuable insights to support the development of HCC of PE teachers both theoretically and practically. Secondly, the research will expand the research scope of health communication.

Theoretical framework

Ecological Systems Theory first proposed by Bronfenbrenner and aim to explain the interactions between individuals and their environment. The theory argues that an individual’s development and behavior are influenced by the environment in which he or she lives, and divides the environment into four different levels: Marcosystem, Exosystem, Mesosystem, Microsystem, each of which has a unique impact on an individual’s development (see Fig. 1 for details)23.

Fig. 1
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Bronfenbrenner’s ecological system theory.

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Macrosystem: Macrosystems are broader cultural and social structures such as culture, social institutions and values. Macrosystems have a profound and long-term impact on an individual’s development because they shape the social and cultural environment in which the individual lives.

Exosystem: Exosystems are environments in which the individual is not directly involved but which have an impact on his or her development, e.g. community resources. These environmental factors can indirectly influence an individual’s development by influencing the microsystem in which he or she lives.

Mesosystem: Mesosystems refer to the interactions and connections between microsystems, such as family, school, colleague. The interactions in mesosystems influence the individual’s experience and development in the different microsystems.

Microsystem: In EST, Microsystem can be conceptualized as face-to-face influence, it can refer to the environment in which individuals are directly involved.

Methods

Sample, sampling, and data collection

The initial interview phase involved 31 health professionals, including both PE teachers and health educators, each with at least two years of experience or formal training in health communication (see Table 1 for details). To ensure diversity and applicability of the findings, participants were selected across different regions, age groups, years of teaching experience, and professional titles. All interviews were audio-recorded and transcribed verbatim, followed by systematic coding using Nvivo 19.0. Based on the qualitative analysis, a set of key influencing factors related to the development of PE teachers’ health communication competence was identified, laying the foundation for the subsequent conceptual framework and quantitative model construction.

Table 1 Demographic characteristics of qualitative participants (N = 31).
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Secondly, in the quantitative part of the study, we used purposive sampling via an online questionnaire (using the Questionnaire Star platform) to survey 394 Chinese primary and secondary school PE teachers. This survey was conducted across four major regions of mainland China (see Table 2 for details).

Table 2 Demographic characteristics of quantitative participants (N = 394).
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As shown in Table 2, a total of 394 PE teachers participated in the study. Most participants were male (67%), aged 26–35 years (62%), and held a bachelor’s degree (60%). Nearly half were second-level teachers (46%), and 43% had 5–10 years of teaching experience. Participants were mainly from western (34%) and eastern (33%) regions, working primarily in urban (32%) and rural (29%) schools.

Factor influencing the formation of PE teacher’ HCC

The framework was developed using qualitative data guided by EST to ensure closer alignment with the research focus. A core interview question was set: what factors do you believe influence the HCC of PE teachers when they are forming? During the interview process, further questions were asked in response to the valuable responses of the interviewees in order to identify the relevant influencing factors.

Social factors

In this study, four observed variables were identified under the dimension of social factors: A1 Social Recognition Degree, A2 Policy Support, A3 Availability of Public Facilities, and A4 Adequacy of the Educational System. These categories were derived through inductive coding, reflecting the broader social environment that influences PE teachers’ HCC. For example, social recognition was frequently mentioned by participants as a key facilitator: “when colleagues and the community value and recognize the concept of health communication, PE teachers are more likely to align with these shared beliefs and actively participate in related practices”. Illustrative excerpts supporting this category are presented in Table 3.

Table 3 Illustrative examples for the category of social factors.
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School factors

Four observed variables were identified under the dimension of school factors: B1 Support and Importance by the School, B2 Implementation of Relevant Training Programs, B3 Availability of Facility Support in School, and B4 Working Environment. These categories reflect how institutional and environmental conditions within schools influence PE teachers’ engagement in health communication practices. In some schools where academic achievement is prioritized over holistic education, PE is often marginalized, with its primary focus limited to teaching motor skills rather than promoting broader health literacy. Under such circumstances, PE teachers may find it difficult to obtain support from school administrators and colleagues when implementing health communication activities, and may even face resistance or skepticism about the legitimacy of their work. Representative excerpts illustrating this category are presented in Table 4.

Table 4 Illustrative examples for the category of school factors.
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Individual factors

Five observed variables were identified under the dimension of individual factors: C1 Personal Awareness, C2 Education Background, C3 Health Communication Knowledge and Skills, C4 Willingness to Learn, and C5 Personal Characteristics. These variables reflect the personal capacities and attributes that shape PE teachers’ engagement in health communication. For instance, personal awareness (C1) refers to teachers’ self-recognition of their educational responsibilities and their willingness to contribute voluntarily to health promotion within the school context. As one participant explained, “If you want to access some health-related information, it is common that you need to pay for a reliable one. In contrast, as an educator, promoting health communication, especially in school settings, is unpaid, which requires strong self-awareness and a sense of dedication.” Representative excerpts for each subcategory are provided in Table 5.

Table 5 Illustrative examples for the category of individual factors.
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Based on the qualitative data analysis, three overarching factors were identified as central to the formation of PE teachers’ health communication competence: social factors, school factors, and individual factors. Each factor consists of several interrelated subcategories that collectively reflect the contextual, institutional, and personal conditions shaping teachers’ competence. Specifically, social factors capture the external environment and policy context that influence teachers’ engagement in health communication; school factors reflect institutional support, resources, and professional development opportunities within schools; and individual factors emphasize teachers’ personal awareness, professional knowledge, and intrinsic motivation for continuous learning. These three major factors and their corresponding subcategories, as derived from inductive coding and constant comparison, are summarized in Table 6.

Table 6 Summary of three major factors and their subcategories identified from qualitative analysis.
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At the macrosystem, social factors such as social recognition degree, policy support, adequacy of the educational system, and availability of public facilities constitute the broader social context. These factors not only directly shape the external environment in which health communication occurs, but also indirectly influence teachers’ competence by affecting the school system—for example, through policy implementation, institutional resource allocation, and cultural recognition of health education. Moreover, social contexts may also shape individual-level attitudes and motivation, determining teachers’ value orientation and willingness to engage in health communication.

At the mesosystem, school factors serve as a bridge linking the macro and micro systems. School support and importance, working environment, implementation of training programs, and facility availability mediate the impact of social contexts and translate macro-level policies into concrete practices. Meanwhile, they exert direct effects on teachers’ professional development, knowledge acquisition, and behavioral engagement in health communication.

At the microsystem, individual factors—including personal awareness, educational background, health communication knowledge and skills, willingness to learn, and personal characteristics—represent the most proximal determinants of competence. These characteristics not only influence teachers’ capacity and motivation to conduct health communication, but also interact with contextual factors. Teachers with strong awareness and motivation are more likely to utilize school resources and respond positively to social support.

In summary, social factors influence school environments and individual characteristics, while school factors mediate and reinforce these influences on teachers’ HCC. The interplay across these three ecological levels highlights that the formation of HCC is not a linear process, but rather an outcome of multi-level interactions within a nested ecological system (see Fig. 2).

Fig. 2
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Theoretical model of the factors influencing the formation of PE teacher’s health communication competence.

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HCC of PE teacher

Health communication competence of PE teachers was measured using a five-point Likert scale ranging from 1 (Not Important) to 5 (Very Important). The items were developed based on the theoretical model established in our previous research, which was constructed using grounded theory (Chen et al., 2023). Ten items were used to measure the HCC of PE teachers.

Study hypothesis

Under the theoretical model above, we propose the hypotheses for this study (see Fig. 3 for details).

Social factors

The participants from interviews frequently discussed how their health communication beliefs were influenced by society. While some participants highlighted the positive influence of social factors on their values, others pointed out that although social factors may not directly impact their beliefs or values regarding health communication, they believe society could gradually shape their beliefs and behaviors in this area. Based on the above, the hypotheses related to SOF as follows:

  • H1a: Social factors have a positive impact on schools.

  • H1b: Social factors have a positive impact on individuals.

  • H1c: Social factors have a positive impact on PE teachers’ health communication competence.

School factors

In contrast to the roles of hospital and health organization personnel, PE teachers are tasked with the dual responsibility of both teaching and health communication within the context of the school environment. Based on the above, the relevant research hypotheses are as follows:

  • H2a: School factors have a positive impact on individuals.

  • H2b: School factors have a positive impact on PE teachers’ health communication.

Individual factors

In our study, participants highlighted that the desire to develop health communication competence is not only tied to professional growth but also to personal development. Based on the above, the hypotheses related to IDF as follows.

  • H3: Individual factors have a positive impact on PE teachers’ health communication competence.

Based on the aforementioned points, the following research hypotheses have been formulated, see Fig. 3 in details:

Fig. 3
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Research hypothesis (Structural Model).

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Statistical analysis and validation

In the quantitative part of the study, we using the SEM approach. Structural Equation Modelling is a powerful tool for explaining complex relationships, validating theoretical hypotheses, assessing intervention effects24. There are numerous algorithms for conducting SEM, with the most widely used methods being Covariance-based Structural Equation Modelling (CB-SEM) and Partial Least Squares Structural Equation Modelling (PLS-SEM)25,26. For the purpose of this study, CB-SEM was chosen. CB-SEM is a parameter estimation method that utilises either covariance matrices or correlation coefficient matrices as input data and typically employs Maximum Likelihood (ML) estimation to estimate model parameters. It assumes that the observed variables follow a multivariate normal distribution26. CB-SEM is commonly employed to validate existing theoretical models, test causal relationships, and explore hierarchical structures25. Therefore, CB-SEM was selected to examine the causal relationships within the theoretical model we constructed, with the aim of elucidating the mechanisms which influencing the formation of HCC among PE teachers.

Before conducting CB-SEM, preliminary analyses were performed to ensure the adequacy of the data. Reliability was assessed using Cronbach’s α coefficients to examine internal consistency across all constructs. Validity was evaluated through both exploratory and confirmatory factor analyses: exploratory factor analysis (EFA) was first conducted to explore the underlying factor structure, including the Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy, Bartlett’s test of sphericity, and principal component analysis (PCA); subsequently, confirmatory factor analysis (CFA) was employed to validate the measurement model and assess convergent and discriminant validity. In addition, multicollinearity diagnostics were carried out by calculating the variance inflation factor (VIF) and tolerance values, confirming that no severe multicollinearity existed among the observed variables.

Ethics approval

This study has been approved by Ethics Board at East China Normal University (HR 608–2021, 5 November 2021). All methods were performed in accordance with the relevant guidelines and regulations as outlined by the Ethics Board at East China Normal University and in compliance with the Declaration of Helsinki.

Informed consent

The researchers obtained informed consent after explaining the purposes, procedures, and voluntary nature. Confidentiality and anonymity in the collection and presentation of results were maintained.

Results

To ensure the independence of exploratory and confirmatory analyses, the dataset was randomly split into two subsamples. The first subsample (n = 184) was used for PCA to explore the underlying factor structure, while the second subsample (n = 210) was used for CFA and subsequent SEM to validate the measurement model and test the hypothesized structural relationships

Reliability and validity analysis

Principal component analysis results

In the PCA, data collected from 184 PE teachers were analyzed. The Cronbach’s alpha coefficients for the subscales and the overall questionnaire ranged from 0.895 to 0.926, demonstrating excellent internal consistency reliability. The KMO measure of sampling adequacy was 0.894, indicating that the correlations among the items were sufficiently high to justify factor analysis. Bartlett’s test of sphericity was significant (χ² = 3386.359, df = 253, p < 0.001), suggesting that the data were appropriate for PCA.

In the PCA, a two-step procedure was adopted because the study included two distinct measurement parts: “PE Teachers’ HCC” and “Influencing Factors.”

Step 1, a separate PCA was conducted for the Health Communication Competence scale. The results indicated that one component could be extracted, with an eigenvalue of 6.125, explaining 61.3% of the total variance. All items loaded strongly on this component (loadings ≥ 0.50), demonstrating good convergent validity and uniqueness.

Step 2, a separate PCA was conducted for the Influencing Factors scale. The analysis extracted three components with eigenvalues of 6.453, 2.944, and 1.120, cumulatively explaining 80.2% of the total variance. In the rotated component matrix, F1 consisted of items 3, 1, 4, 5, and 2; F2 consisted of items 8, 9, 7, and 6; and F3 consisted of items 11, 10, 12, and 13. All items had substantial loadings (≥ 0.79) on their respective factors, indicating clear factor structures (see Table 7 for details).

Table 7 Rotated component matrix and uniqueness values (two independent steps).
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Confirmatory factor analysis results

In the SEM analysis, the influencing factors and HCC were integrated into a unified structural model. Accordingly, a CFA was conducted to validate a measurement model consisting of four latent constructs: Social Factors, School Factors, Individual Factors, and HCC.

The model fit indices indicated an acceptable model fit (χ²/df = 2.47, CFI = 0.90, TLI = 0.89, RMSEA = 0.08). All standardized factor loadings exceeded 0.50 and were statistically significant (p < 0.001), suggesting that each observed variable effectively represented its respective latent construct (see Table 8 for details). The Cronbach’s alpha coefficients ranged from 0.859 to 0.926, demonstrating satisfactory internal consistency reliability across all constructs.

Table 8 Standardized factor loadings, standard errors, and significance levels from the CFA.
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Furthermore, the composite reliability (CR) values ranged from 0.861 to 0.921, all exceeding the recommended threshold of 0.70, and the average variance extracted (AVE) values ranged from 0.538 to 0.669, all greater than 0.50, indicating adequate convergent validity. In addition, the square roots of the AVE values were greater than the inter-factor correlations, providing evidence for satisfactory discriminant validity. Overall, these results suggest that the measurement model demonstrated good reliability and validity, supporting its use in subsequent SEM analysis.

Structural equation model (SEM)

Descriptive analysis

The normality of the data was assessed using skewness and kurtosis statistics. All variables exhibited skewness values below 2 and kurtosis values below 5, indicating approximate univariate normality27. Thus, the assumption of normality was met for subsequent SEM analyses.

Multicollinearity test results

A multicollinearity test was conducted for all measurement items. The results showed that the VIF values ranged from 2.27 to 3.89 (all < 5), and the tolerance values ranged from 0.26 to 0.44 (all > 0.2), indicating that there were no serious multicollinearity problem and the data were suitable for subsequent SEM analysis (see Table 9 for details).

Table 9 Multicollinearity test results for measurement items.
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Model fit

Based on the hypothesized model, four latent factors were identified and denoted as A, B, C, and D for clarity. Specifically, Factor A represented Social Factors, Factor B represented School Factors, Factor C represented Individual Factors, and Factor D represented PE Teachers’ HCC. The corresponding observed variables were labeled as A1–A4, B1–B4, C1–C5, D1a–D1c, D2a–D2b, and D3a–D3e. The standardized path coefficients and model fit results are presented in Fig. 4.

Fig. 4
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Structural equation model results.

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The CFI has a value of 0.916, the NNFI is 0.905, the RMR is 0.097, the RMSEA is 0.076, the DF is 2.124, and the IFI is 0.917. These indicators provide information about how well the model fits the observed data. In this case, all of these indicators meet the standard criteria, suggesting a good fit of the model.

Model results

According to the structural equation model, the hypothesis testing results are summarized in Table 10:

Table 10 Model verification results.
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It can be observed that all three factors have a positive influence on the HCC of PE teachers, in accordance with the theoretical hypothesis model presented in this study. In terms of the magnitude of influence, the total effect value of social factors is 0.396, ranking first, followed by the total effect value of school factors at 0.379, ranking second, and the total effect value of individual factors at 0.210, ranking third.

Rank of observation variables for influential factors

A composite weighting approach was employed to evaluate and rank the influencing factors of PE teachers’ HCC. By multiplying the path coefficients of each observed variable by the total effect of its corresponding latent variable, a comprehensive index for each factor was obtained and ranked in descending order. As shown in Table 11, the results suggest that PE teachers tend to attribute the formation of HCC more to external factors, with A2 Policy Support, A1 Social Recognition Degree, and B2 Implementation of Relevant Training Programs ranking first, second, and third, respectively.

Table 11 Ranking of comprehensive index of influencing factors in the formation of HCC.
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Discussion

This study aims to explore the factors influencing the development of HCC in PE teachers, guided by three central questions: (1) How do PE teachers perceive and experience the factors that shape their health communication competence? (2) To what extent do these factors genuinely contribute to the competence development, and how do they vary in influence? (3) What are the characteristics of PE teachers’ HCC when they are formed? Do these align with the EST theory? The findings reveal that (1) HCC among PE teachers is influenced by multiple factors, with social factors (0.396), school factors (0.379), and individual factors (0.210) playing significant roles. Thirteen sub-factors contribute to these influences. (2) The top three contributing factors include policy support, social recognition degree, and the implementation of relevant training programs. (3) The formation of PE teachers’ HCC is influenced by the hierarchical structure of Macro, Exo, Meso, and Microsystems in the EST, with interactions among these levels. However, among them, the Macro and Exo levels, namely social factors, have the most significant impact on the HCC of PE teachers.

Structural determinants and institutional integration of HCC

The cultivation of HCC among PE teachers is deeply embedded in a broader structural ecology shaped by policy, social perception, and institutional capacity. As this study indicates, policy support and social recognition jointly constitute the most influential drivers, demonstrating that health communication cannot be effectively strengthened without systemic legitimacy and public endorsement. Consistent with the principles of the social determinants of health28, the social and political environment provides both enabling and constraining conditions for teachers’ professional enactment. The blurred and sometimes contradictory policy boundaries between education and health domains further complicate the implementation of communication initiatives. Although the National K12 PE and Health Curriculum Standards (2022 Edition) designate PE teachers as essential actors in school health education29, their roles and responsibilities in health communication remain vaguely defined. This ambiguity limits teachers’ confidence and creates inconsistencies in practice. Clarifying the national policy framework, aligning educational and health agendas, and establishing evaluation mechanisms would therefore provide both clarity and incentive for teachers’ engagement in systematic, evidence-based communication activities.

This policy-practice gap is rooted in a structural disconnect between education and health systems, where the formal recognition of PE teachers’ roles often lacks institutional alignment and operational clarity. Although national policies acknowledge PE teachers as key agents of health education, weak inter-system coordination limits their capacity to implement communication tasks effectively. This misalignment reflects broader global concerns about the divide between health and education governance. The unclear delineation of communication responsibilities and the absence of coordinated support mechanisms further reinforce this institutional gap.

Furthermore, the current professional training environment appears to reinforce this fragmentation. Despite the recognized importance of teacher development, many training programs remain narrowly oriented toward sports pedagogy rather than integrative health communication, limiting their relevance and practical transferability. Similar challenges have been documented internationally, where professional preparation often fails to bridge disciplinary divides30,31. As a result, PE teachers frequently face inadequate institutional capacity—uneven access to health-related teaching materials, fitness facilities, and communication resources—which constrains their ability to engage students effectively. Addressing these issues requires a multilevel strategy that not only enhances resource allocation but also redefines training systems to embed health communication as a central component of professional identity. By positioning PE teachers as credible and competent health communicators, school-based health education can simultaneously advance equity and cost-effectiveness, reinforcing its role as a sustainable pathway for public health promotion32.

Contextual constraints and the lag in policy implementation

The limited development of HCC among PE teachers is further compounded by contextual constraints arising from delayed policy implementation and insufficient health awareness. Although numerous national policies have been issued to promote physical activity and school-based health initiatives, the translation of these policies into practice remains slow and uneven across regions33. The fragmented pre-service and in-service training systems for PE teachers lack an integrated framework for health communication, leaving educators without systematic guidance or institutional support. Moreover, the absence of detailed national physical activity guidelines and clear role definitions within the education sector contributes to weak compliance and inconsistent delivery34. Such policy–practice gaps are not unique to China; comparable challenges have been observed in other countries where limited enforcement and resource disparities hinder teachers’ engagement in school-based health promotion35. This phenomenon aligns with the observed deficiencies in facility availability (B3) and educational system adequacy (A4), revealing that institutional and infrastructural shortcomings significantly impede the operationalization of teachers’ communicative functions.

Societal attitudes further intensify these systemic challenges. Despite increasing public awareness of the consequences of sedentary behaviour and physical inactivity, preventive health consciousness remains low36,37. The cultural hierarchy of authority in health discourse—where physicians and nurses are traditionally regarded as the primary opinion leaders—also undermines the legitimacy of PE teachers’ health-related communication efforts38. Consequently, even when PE teachers disseminate accurate information, students and parents may question its validity. To address these challenges, both top-down policy reinforcement and bottom-up cultural recognition are essential. Strengthening policy mandates, improving interdepartmental coordination, and enhancing public trust would together position PE teachers as legitimate, trusted, and sustainable agents of health communication. Comparative research across different cultural and institutional contexts could further clarify how national education systems can mobilize PE teachers to promote health equity and long-term behavioural change.

Limitations and future research

This study employed a cross-sectional design to explore predictive relationships derived from theoretical frameworks and previous empirical findings. While this design provided valuable insights into the factors influencing PE teachers’ HCC, it cannot capture causal or temporal dynamics among variables. Future studies should therefore adopt longitudinal or intervention-based designs to examine how HCC evolves over time and how targeted strategies may enhance it. Additionally, the context-specific nature of the current measurement instrument—developed within a particular educational and cultural environment—may limit its applicability to other regions or educational settings. Potential social desirability bias should also be acknowledged, as participants may have overreported positive attitudes or competencies related to health communication.

The relatively limited sample size further constrains the generalizability of the results. To strengthen the external validity and robustness of future findings, subsequent studies should expand sample coverage across diverse geographic regions and school contexts. In addition to increasing sample size, future research could advance by developing standardized and context-sensitive evaluation scales tailored to assess PE teachers’ HCC more precisely.Moreover, insights from comparative research across diverse cultural and institutional contexts could provide valuable guidance for advancing the health communication practices of PE teachers in China and other countries, contributing to more equitable and sustainable health promotion efforts.

Conclusions

This study is based on the EST and uses CB-SEM to verify the influencing mechanism in the formation process of PE teachers’ HCC. The results show that EST is a powerful theory to understand the forming mechanism of the HCC of PE teachers. In addition, the influence of external factors (social factors, school factors) is greater than that of internal factors (individual factors).

The implications of this study are twofold: (1) It helps PE teachers identify the factors and mechanism that may affect the formation of their HCC, allowing them to address these factors and improve their deficiencies in HCC. (2) As primary influencing factors, in order to facilitate the development of HCC among PE teachers, it is essential that both governmental and societal levels provide policy and public opinion support.