***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: The integration of realist evaluation principles within r and omised controlled trials ( ‘ realist RCTs ’ ) enables evaluations of complex interventions to answer questions about what works , for whom and under what circumstances . This allows evaluators to better develop and refine mid-level programme theories . However , this is only one phase in the process of developing and evaluating complex interventions . We describe and exemplify how social scientists can integrate realist principles across all phases of the Medical Research Council framework . Intervention development , modelling , and feasibility and pilot studies need to theorise the context ual conditions necessary for intervention mechanisms to be activated . Where interventions are scaled up and translated into routine practice , realist principles also have much to offer in facilitating knowledge about longer-term sustainability , benefits and harms . Integrating a realist approach across all phases of complex intervention science is vital for considering the feasibility and likely effects of interventions for different localities and population subgroups Steps to Respect : A  Bullying Prevention Program ( STR ) relies on a social – ecological model of prevention to increase school staff awareness and responsiveness , foster socially responsible beliefs among students , and teach social – emotional skills to students to reduce bullying behavior . As part of a school-r and omized controlled trial of STR , we examined predictors and outcomes associated with classroom curriculum implementation in intervention schools . Data on classroom implementation ( adherence and engagement ) were collected from a sample of teachers using a weekly on-line Teacher Implementation Checklist system . Pre-post data related to school bullying-related outcomes were collected from 1,424 students and archival school demographic data were obtained from the National Center for Education Statistics . Results of multilevel analyses indicated that higher levels of program engagement were influenced by school-level percentage of students receiving free/reduced lunch , as well as classroom-level climate indicators . Results also suggest that higher levels of program engagement were related to lower levels of school bullying problems , enhanced school climate and attitudes less supportive of bullying . Predictors and outcomes related to program fidelity ( i.e. , adherence ) were largely nonsignificant . Results suggest that student engagement is a key element of program impact , though implementation is influenced by both school-level demographics and classroom context R and omized trials of complex public health interventions generally aim to identify what works , accrediting specific intervention ' products ' as effective . This approach often fails to give sufficient consideration to how intervention components interact with each other and with local context . ' Realists ' argue that trials misunderst and the scientific method , offer only a ' successionist ' approach to causation , which brackets out the complexity of social causation , and fail to ask which interventions work , for whom and under what circumstances . We counter-argue that trials are useful in evaluating social interventions because r and omized control groups actually take proper account of rather than bracket out the complexity of social causation . Nonetheless , realists are right to stress underst and ing of ' what works , for whom and under what circumstances ' and to argue for the importance of theorizing and empirically examining underlying mechanisms . We propose that these aims can be ( and sometimes already are ) examined within r and omized trials . Such ' realist ' trials should aim to : examine the effects of intervention components separately and in combination , for example using multi-arm studies and factorial trials ; explore mechanisms of change , for example analysing how pathway variables mediate intervention effects ; use multiple trials across context s to test how intervention effects vary with context ; draw on complementary qualitative and quantitative data ; and be oriented towards building and validating ' mid-level ' program theories which would set out how interventions interact with context to produce outcomes . This last suggestion resonates with recent suggestions that , in delivering truly ' complex ' interventions , fidelity is important not so much in terms of precise activities but , rather , key intervention ' processes ' and ' functions ' . Realist trials would additionally determine the validity of program theory rather than only examining ' what works ' to better inform policy and practice in the long-term Organizational climate has been proposed as a factor that might influence a school ’s readiness to successfully implement school-wide prevention programs . The aim of this study was to evaluate the influence of teachers ’ perceptions of three dimensions of school organizational climate on the dosage and quality of teacher implementation of Positive Action , a social-emotional and character development ( SECD ) program . The dimensions measured were teachers ’ perceptions of ( a ) the school ’s openness to innovation , ( b ) the extent to which schools utilize participatory decision-making practice s , and ( c ) the existence of supportive relationships among teachers ( teacher-teacher affiliation ) .  Data from 46 teachers in seven schools enrolled in the treatment arm of a longitudinal , cluster-r and omized , controlled trial were analyzed . Teacher perceptions of a school ’s tendency to be innovative was associated with a greater number of lessons taught and self-reported quality of delivery , and teacher-teacher affiliation was associated with a higher use of supplementary activities . The findings suggest that perceptions of a school ’s organizational climate impact teachers ’ implementation of SECD programs and have implication s for school administrators and technical assistance providers as they work to implement and sustain prevention programs in schools The Gatehouse Project is an innovative , comprehensive approach to mental health promotion in secondary schools . It sets out to promote student engagement and school connectedness as the way to improve emotional well-being and learning outcomes . The key elements of the whole-school intervention are the establishment and support of a school-based adolescent health team ; the identification of risk and protective factors in each school ’s social and leaning environment from student surveys ; and , through the use of these data , the identification and implementation of effective strategies to address these issues . The project evaluation used a cluster-r and omized controlled trial design involving 26 schools with initial results demonstrating considerable success in reducing smoking rates among Year 8 children . This article describes and accounts for how system-level changes have been made in schools through a process of capacity building . This encourages teachers , parents , and students to view the core business of education differently 
    Output:
    
Key facilitators of integrated academic and health curricula were supportive senior management and alignment of the intervention with school ethos ; a positive teaching environment , including positive perceptions around the ability to be flexible in the adaptation and delivery of integrated academic and health curricula ; positive pre-existing student and teacher attitudes towards intervention content ; and parental support of interventions , largely through reinforcement of messaging at home .
Important barriers were over-burdened teachers , with little time to learn and implement integrated curricula .
ConclusionS everal useful facilitating and inhibiting factors linked to the implementation of interventions that integrate academic and health education for reduced substance use and /or violence were identified , providing tentative but insightful evidence of context -specific issues that may impact intervention success .