***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: Background Multi-component interventions combining educational and environmental strategies have proved effective in increasing children and adolescents ’ fruit and vegetable intake . However such interventions are complex and difficult to implement and several studies report poor implementation . There is a need for knowledge on the role of dose for behaviour change and for assessment of intervention dose to avoid conclusions that intervention components which are not implemented are ineffective . This study aim ed to examine 1 ) the association between dose of a class curriculum and adolescents ’ fruit and vegetable intake in a school-based multi-component intervention , 2 ) if gender and socioeconomic position modify this association . Methods We carried out secondary analysis of data from intervention schools in the cluster-r and omized Boost study targeting 13-year-olds ’ fruit and vegetable intake . Teacher- and student data on curriculum dose delivered and received were aggregated to the school-level and class-level ( only possible for student data ) . We analysed the association between curriculum dose and students ’ ( n 995 ) self-reported fruit and vegetable intake ( 24-h recall question naire ) after finalization of the intervention using multi-level analyses . Potential moderation was examined by analyses stratified by gender and socioeconomic position . Results Average dose received at class-level was significantly associated with students ’ fruit and vegetable intake ( 10 g ( CI : 0.06 , 20.33 ) per curricular activity received ) . In stratified analyses the association remained significant among boys only ( 14 g ( CI : 2.84 , 26.76 ) per curricular activity received ) . The average dose delivered and received at the school-level was not significantly associated with students ’ intake . Conclusions We found a dose — response relationship between number of curricular activities received and adolescents ’ fruit and vegetable intake . The results indicate that curriculum dose received only mattered for promotion of fruit and vegetable intake among boys . Future studies should explore this gender difference in larger sample s to guide the planning of school-based curricular interventions with regards to the optimal number of curricular activities required to promote behavioural change in subgroups with low fruit and vegetable intake at baseline . Trial registration Current Controlled Trials IS RCT N11666034 Background To unravel the effect of school-based nutrition education , insight into the implementation process is needed . In this study , process indicators of Taste Lessons ( a nutrition education programme for Dutch elementary schools ) and their association with changes in behavioural determinants relevant to healthy eating behaviour are studied . Methods The study sample consisted of 392 Dutch primary school children from 12 schools . Data were collected using teacher and child question naires at baseline , and at one and six months after the intervention . Multilevel regression analyses were conducted to study the association between dose , appreciation and children ’s engagement in  interpersonal communication ( talking about Taste Lessons with others after the lessons ) , and change in knowledge , awareness , skills , attitude , emotion , subjective norm and intention towards two target behaviours . Results With an average implementation of a third of the programme activities , dose positively predicted change in children ’s subjective norm of the teacher after one month . Teachers and children highly appreciated Taste Lessons . Whereas teacher appreciation was inversely associated , child appreciation was positively associated with children ’s change in awareness , emotion and subjective norm of teachers after one month and in attitude and subjective norm of parents after six months . Interpersonal communication was positively associated with children ’s change in five determinants after one month and in attitude and intention after six months . Conclusions The implementation process is related to the programme outcomes of Taste Lessons . Process data provide valuable insights into factors that contribute to the effect of interventions in real-life setting BACKGROUND Pathways , a multisite school-based study aim ed at promoting healthful eating and increasing physical activity , was a r and omized field trial including 1704 American Indian third to fifth grade students from 41 schools ( 21 intervention , 20 controls ) in seven American Indian communities . METHODS The intervention schools received four integrated components : a classroom curriculum , food service , physical activity , and family modules . The curriculum and family components were based on Social Learning Theory , American Indian concepts , and results from formative research . Process evaluation data were collected from teachers ( n=235 ) , students ( n=585 ) , and families .  Knowledge , Attitudes , and Behavior Question naire data were collected from 1150 students including both intervention and controls . RESULTS There were significant increases in knowledge and cultural identity in children in intervention compared to control schools with a significant retention of knowledge over the 3 years , based on the results of repeating the third and fourth grade test items in the fifth grade . Family members participated in Family Events and take-home activities , with fewer participating each year . CONCLUSION A culturally appropriate school intervention can promote positive changes in knowledge , cultural identity , and self-reported healthful eating and physical activity in American Indian children and environmental change in school food service Background Physical Activity Across the Curriculum ( PAAC ) is a 3-year elementary school-based intervention to determine if increased amounts of moderate intensity physical activity performed in the classroom will diminish gains in body mass index ( BMI ) . It is a cluster-r and omized , controlled trial , involving 4905 children ( 2505 intervention , 2400 control ) . Methods We collected both qualitative and quantitative process evaluation data from 24 schools ( 14 intervention and 10 control ) , which included tracking teacher training issues , challenges and barriers to effective implementation of PAAC lessons , initial and continual use of program specified activities , and potential competing factors , which might contaminate or lessen program effects . Results Overall teacher attendance at training sessions showed exceptional reach . Teachers incorporated active lessons on most days , result ing in significantly greater student physical activity levels compared to controls ( p < 0.0001 ) . Enjoyment ratings for classroom-based lessons were also higher for intervention students . Competing factors , which might influence program results , were not carried out at intervention or control schools or were judged to be minimal . Conclusion In the first year of the PAAC intervention , process evaluation results were instrumental in identifying successes and challenges faced by teachers when trying to modify existing academic lessons to incorporate physical activity This study reports the effect of the Fruits and Vegetables Make the Marks intervention , a school-based fruit and vegetable intervention consisting of a home economics classroom component and parental involvement and encouraged participation in the Norwegian School Fruit Programme , all delivered during the school year of 2001 - 02 . Nine r and omly chosen schools received the intervention and 10 schools served as control schools . Participating pupils completed question naires at baseline ( September 2001 ) , at Follow-up 1 ( May-June 2002 ) and at Follow-up 2 ( May 2003 ) . A total of 369 pupils ( 69 % ; mean age , 11.3 years at baseline ) participated in all three surveys . No effect of the intervention was found for intake of fruit and vegetables eaten at school or all day , neither at Follow-up 1 nor at Follow-up 2 . On analysing the effects on potential mediators , significant differences between intervention and control groups were found for Awareness of the five-a-day recommendations only . The intervention programme was rated as very good by the teachers , and the pupils reported that they enjoyed it . However , the intervention failed to change fruit and vegetable intake , probably because it did not succeed in changing the pupils ' preferences for or the accessibility of fruit and vegetables -- the two strongest correlates of children 's fruit and vegetable intake Background The worldwide increase in the rates of childhood overweight and physical inactivity requires successful prevention and intervention programs for children . The aim of the Active Living project is to increase physical activity and decrease sedentary behavior of Dutch primary school children by developing and implementing tailored , multicomponent interventions at and around schools . Methods / design In this project , school-centered interventions have been developed at 10 schools in the south of the Netherl and s , using a combined top-down and bottom-up approach in which a research unit and a practice unit continuously interact . The interventions consist of a combination of physical and social interventions tailored to local needs of intervention schools . The process and short- and long-term effectiveness of the interventions will be evaluated using a quasi-experimental study design in which 10 intervention schools are matched with 10 control schools . Baseline and follow-up measurements ( after 12 and 24 months ) have been conducted in grade s 6 and 7 and included accelerometry , GPS , and question naires . Primary outcome of the Active Living study is the change in physical activity levels , i.e. sedentary behavior ( SB ) , light physical activity ( LPA ) , moderate-to-vigorous physical activity ( MVPA ) , and counts-per-minute ( CPM ) . Multilevel regression analyses will be used to assess the effectiveness of isolated and combined physical and social interventions on children ’s PA levels . Discussion The current intervention study is unique in its combined approach of physical and social environmental PA interventions both at school(yard)s as well as in the local neighborhood around the schools . The strength of the study lies in the quasi-experimental design including objective measurement techniques , i.e. accelerometry and GPS , combined with more subjective techniques , i.e. question naires , implementation logbooks , and neighborhood observations . Trial registration Current Controlled Trials IS RCT N25497687 ( registration date 21/10/2015 ) , METC 12 - 4 - 077 , Project number Purpose : To test the feasibility of Kids SIPsmartER , a school-based intervention to reduce consumption of sugar-sweetened beverages ( SSBs ) . Design : Matched-contact r and omized crossover study with mixed- methods analysis . Setting : One middle school in rural , Appalachian Virginia . Participants : Seventy-four sixth and seventh grade rs ( 5 classrooms ) received Kids SIPsmartER in r and om order over 2 intervention periods . Feasibility outcomes were assessed among 2 teachers . Intervention : Kids SIPsmartER consisted of 6 lessons grounded in the Theory of Planned Behavior , media literacy , and public health literacy and aim ed to improve individual SSB behaviors and underst and ing of media literacy and prevalent regional disparities . The matched-contact intervention promoted physical activity . Measures : Beverage Intake Question naire-15 ( SSB consumption ) , vali date d theory question naires , feasibility question naires ( student and teacher ) , student focus groups , teacher interviews , and process data ( eg , attendance ) . Analysis : Repeated measures analysis of variances across 3 time points , descriptive statistics , and deductive analysis of qualitative data . Results : During the first intervention period , students receiving Kids SIPsmartER ( n = 43 ) significantly reduced SSBs by 11 ounces/day ( P = .01 ) and improved media ( P < .001 ) and public health literacy ( P < .01 ) underst and ing ; however , only media literacy showed between-group differences ( P < .01 ) . Students and teachers found Kids SIPsmartER acceptable , in-dem and , practical , and implementable within existing re sources . Conclusion : Kids SIPsmartER is feasible in an underre source d , rural school setting . Results will inform further development and large-scale testing of Kids SIPsmartER to reduce SSBs among rural adolescents This study investigates the link between process evaluation components and the outcomes of a  school-based nutrition curriculum intervention , ' Choice , Control and Change ' . Ten New York City public middle schools were recruited and r and omly assigned into intervention or control condition . The curriculum was to improve sixth to seventh grade students ' energy balance related behaviors , based on social cognitive and self-determination theories , and implemented during the 2006 - 2007 school year ( n = 1136 ) .  Behaviors and psychosocial variables were measured by self-reported question naires . Process components were evaluated with classroom observations , teacher interviews , and a student question naire . Using ' Teacher Implementation ' ( dose delivered ) and ' Student Reception ' ( dose received ) process data ; intervention group was further categorized into medium- and high-implementation groups . Analysis of covariance revealed that , compared with control group , only high-implementation group showed significant improvement in students ' behavior and psychosocial outcomes . Hierarchical linear models showed that ' Teacher Implementation ' and ' Student Reception ' significantly predicted students ' sweetened beverage outcomes ( P < 0.05 ) . ' Student Satisfaction ' was also greater when these implementation components were higher , and significantly associated with behavior and psychosocial outcomes ( P < 0.05 ) . Implementation process influenced the effectiveness of the ' Choice , Control and Change ' intervention study . It is important to take into account the process components when interpreting the results of such research This article describes the process evaluation of High 5 , a  school-based intervention targeting fruit and vegetable consumption among fourth grade rs and their families . The outcome evaluation involved 28 schools r and omized to intervention or control conditions . The intervention included classroom , family , and cafeteria components .  Process evaluation was completed on each of these components by using observations , self-report checklists , surveys , and other measures . Results indicated high implementation rates on the classroom activities . Moderate family involvement was attained , perhaps diminishing intervention effects on parent consumption . Cafeterias provided environmental cues , and fruit and vegetable offerings as directed by the program . A lower dose of the intervention was delivered to schools with larger African American enrollments and lower-income families . This article provides insights into the effective elements of a school-based dietary intervention and provides suggestions for process evaluation in similar studies Project FIT was a two-year multi-component nutrition and physical activity intervention delivered in ethnically-diverse low-income elementary schools in Gr and Rapids , MI . This paper reports effects on children ’s nutrition outcomes and process evaluation of the school component . A quasi-experimental design was utilized . 3rd , 4th and 5th- grade students ( Yr 1 baseline : N = 410 ; Yr 2 baseline : N = 405 ; age range : 7.5–12.6 years ) were measured in the fall 
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Moreover , research ers should focus on the relation between fidelity and programme outcomes and determine to what extent adaptations to programmes have been made , whilst still being effective