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Embedding effective programs into routine practices of frontline settings is a global priority for mental health prevention, however, little is known about what strategies effectively support program implementation in schools. The purpose of this study was to test the effect of a multicomponent implementation strategy on the adoption and efficacy of the PAX Good Behavior Game, using a cluster randomized controlled trial with a type-3 implementation-effectiveness design. The trial was conducted in 25 primary schools across New South Wales, Australia. Schools were randomly assigned to receive the PAX Good Behavior Game\n                    <jats:italic>plus<\/jats:italic>\n                    an implementation toolkit to support adoption (intervention group) or the PAX Good Behavior Game only (control group). The primary outcome was change in rate of program adoption, measured as current use or support of the PAX Good Behavior Game, first measured at 6\u00a0weeks post-registration (T0). The secondary effectiveness measure was change in students\u2019 emotional and behavioral problems, using the teacher-reported Strengths and Difficulties Questionnaire (SDQ). The first measure of the SDQ occurred at trial registration, prior to program implementation (T0). Both adoption and effectiveness were re-measured at 6\u00a0months post-registration (T1). All data were analyzed using intention-to-treat methods. Early program adoption was higher in the intervention group compared to control group (93.6% vs 45.2%: OR\u2009=\u200921.20, 95% CI [3.50, 128.45],\n                    <jats:italic>z<\/jats:italic>\n                    \u2009=\u20093.32,\n                    <jats:italic>p<\/jats:italic>\n                    \u2009&lt;\u20090.001), with no differential effects at 6\u00a0months (96.8% vs 95.7%: OR\u2009=\u20091.21, 95% CI [0.16, 9.04],\n                    <jats:italic>z<\/jats:italic>\n                    \u2009=\u20090.18,\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.855). Emotional and behavioral problems reduced in both groups from baseline to 6\u00a0months (\n                    <jats:italic>p<\/jats:italic>\n                    \u2009&lt;\u20090.001,\n                    <jats:italic>d<\/jats:italic>\n                    \u2009= \u2212\u20090.25), with no differential effects observed at T1 (\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.474,\n                    <jats:italic>d<\/jats:italic>\n                    \u2009= \u2212\u20090.08). There was a positive linear relationship between adoption and the perceived acceptability, appropriateness, and feasibility of the program for the pooled sample. It seems that providing implementation support early in the process of establishing new innovations in schools may help accelerate early adoption by increasing perceived appropriateness and acceptability, but uncertainty remains as to what support is needed to optimize implementation and effectiveness longer term. The protocol was retrospectively registered with the Australian New Zealand Clinical Trials Registry, ACTRN12621001125819.\n                  <\/jats:p>","DOI":"10.1007\/s11121-025-01870-3","type":"journal-article","created":{"date-parts":[[2026,2,6]],"date-time":"2026-02-06T02:34:01Z","timestamp":1770345241000},"page":"301-315","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Using a Multicomponent Implementation Strategy to Increase Adoption and Effectiveness of a Universal Mental Health Prevention Program in Australian Primary Schools: a Cluster Randomized Trial Using a Type-3 Hybrid Design"],"prefix":"10.1007","volume":"27","author":[{"given":"Rachel","family":"Baffsky","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Quincy J.J.","family":"Wong","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Patricia","family":"Cullen","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Aliza","family":"Werner-Seidler","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alison L.","family":"Calear","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Philip J.","family":"Batterham","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"John W.","family":"Toumbourou","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lauren","family":"McGillivray","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bridianne","family":"O\u2019Dea","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rebecca","family":"Ivers","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3741-8075","authenticated-orcid":false,"given":"Michelle","family":"Torok","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2026,2,6]]},"reference":[{"key":"1870_CR1","doi-asserted-by":"publisher","DOI":"10.1016\/j.conctc.2022.100923","volume":"28","author":"R Baffsky","year":"2022","unstructured":"Baffsky, R., Ivers, R., Cullen, P., Batterham, P. 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We certify that the study was performed in accordance with the ethical standards outlined in the 1964 Declaration of Helsinki and its later amendments.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"<!--Emphasis Type='Bold' removed-->Ethics Approval"}},{"value":"Opt-in informed consent was obtained from all participants included in the study.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent to Participate"}},{"value":"The authors have no relevant financial or non-financial interests to disclose. The PAXIS Institute, owners of the PAX Good Behavior Game, provided the NSW Department of Education with support to establish the PAX program but were not involved in the design, conduct, or interpretation of this trial, and did not provide any funding or support to the trial.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}}]}}