Disparities in practice: implementation of health promotion policies in 2883 Hungarian schools with a focus on small-sized institutions.

While Holistic Health Promotion is mandated in Hungary, little is known about its school-level implementation, especially in small schools. We analyzed national data of 2883 elementary schools, and (i) compared the implementation between small (10-99 students) and not-small schools, and (ii) conducted county-level socioeconomic comparisons within the subsample of small schools. Health promotion activities were implemented inconsistently across schools. Small schools (N = 320) reported fewer structured working groups (9.7%) and lower engagement of school health staff in program development (doctors: 3.1%, nurses: 6.9%, psychologists: 0.9%). Participation in national food schemes was markedly higher in low socioeconomic status (SES) areas than in high SES small schools (Milk Scheme: 83.5% vs. 46.5; Fruit & Vegs Scheme: 86.9% vs. 67.3%). Menu planning was aligned with the Public Catering Act in two-thirds of all schools (68.9%), which falls short of full adherence. Coverage of nutrition education was high (95.5%). Experiential learning tools like school gardens (31.7%) and educational kitchens (18.8%) were predominantly found in high SES context. After-school physical activity opportunities were significantly limited in small schools. The availability of bullying (32.2%) and digital addictions (52.2%) prevention measures was limited in low SES context. Parental health literacy programs showed moderate integration across all groups (average score: 6 out of 10). This study provides the first nationwide school-level evidence on variation in the implementation of health promotion policies. Findings highlight modest differences by size and SES, and underscore the need for targeted actions to support small and disadvantaged schools.