Process evaluation of Project Daire: a food environment intervention that impacted food knowledge, wellbeing and dietary habits of primary school children

Process evaluation of Project Daire: a food environment intervention that impacted food knowledge, wellbeing and dietary habits of primary school children | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Process evaluation of Project Daire: a food environment intervention that impacted food knowledge, wellbeing and dietary habits of primary school children Naomi Anderson, Sarah F. Brennan, Fiona Lavelle, Sarah E. Moore, and 11 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3757991/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Feb, 2025 Read the published version in BMC Public Health → Version 1 posted 14 You are reading this latest preprint version Abstract Background: The Project DAIRE trial aimed to improve children’s health-related quality of life, wellbeing, food knowledge and dietary habits via two multi-component interventions: Nourish, and Engage. Nourish was an intervention aiming to alter the school food environment, provide food-based experiences and expose pupils to locally produced foods. Engage was an age-appropriate cross-curricular food education intervention incorporating food, agriculture, nutrition science and related careers. The purpose of this study was to conduct a mixed methods process evaluation to evaluate DAIRE implementation, mechanisms of impact (MOI) and context, and inform scalable implementation of the DAIRE approach. Methods: The Medical Research Council’s (MRC) framework for process evaluation was followed. Formal and informal methods were used to collect quantitative and qualitative data during the DAIRE trial in relation to process evaluation. Quantitative data were analysed using descriptive statistics and qualitative data via thematic analysis to identify key themes. Results: Fifteen schools and 983 pupils (n=495 Key Stage 1 (KS1) and n=488 Key Stage 2 (KS2) pupils) were recruited for the 6-month DAIRE intervention; a 100% retention rate was observed at the school level and the interventions had a high level of acceptability. Nourish schools implemented a higher mean intervention dose (57.2%) than Engage (50%) schools but, overall, mixed implementation of both interventions occurred. DAIRE produced change through four key MOI: social learning, experimental learning, interactive engaging content and real-life connections. Lack of time was the main contextual barrier to DAIRE implementation and lack of financial cost to schools was indicated as a potential facilitator. Conclusions: This process evaluation helped to identify important findings related to implementation, MOI and context. The most effective elements of the interventions which should be maintained include provision of interactive and engaging intervention elements and ensure these are at no financial cost to the school. Findings also identified suggestions for improvement including provision of increased teacher training, support and planning time, content reduction to facilitate easy integration into the school curriculum, and implementation across the full academic year. A sustainable funding and resourcing mechanism is required for successful future roll-out. Trial Registration : The original trial referenced in this process evaluation is registered as follows: National Institute of Health (NIH) U.S. National Library of Medicine Clinical Trials.gov (ID: NCT04277312) Process evaluation School Children Diet Food Education Childhood wellbeing Child behaviour Food environment Whole-school approach Figures Figure 1 Background The link between childhood diet and disease prevention in adulthood is well established and research suggests that eating patterns track from childhood to adulthood ( 1 , 2 , 3 ). Consequently, establishing healthy dietary patterns in childhood is critical to influencing future disease risk and adult health status ( 1 , 2 , 3 ). Schools have been recognized as ideal environments for public health interventions ( 4 ) due to the proportion of time children spend in school and the significant number of meals consumed in this setting. As such, calls for action to policy makers to improve the dietary quality of food provided in the school setting has intensified ( 5 , 6 ) and a whole-school approach advocated ( 5 ). DAIRE was a school-based randomised-controlled, factorial design four-arm trial conducted in Northern Irish (NI) primary school settings. DAIRE tested elements of the whole school approach through two interventions – Nourish and Engage. Nourish was a food environment intervention which focused on food provision, resources to improve school food presentation and the school food environment, fun-based food-related experiences and exposure to locally produced foods. Engage was an age-appropriate cross-curricular food education intervention, which involved educational food topics, interactive lessons and engaging food experiences in the community. Project Daire worked in partnership with primary schools and a range of stakeholders, including teachers, principals, school caterers and local food producers, to develop and deliver the interventions. The study demonstrated that improvements in childhood emotional and behavioural wellbeing, dietary intake, knowledge about food, cooking skills and willingness to try new foods were associated with the ‘Nourish’ whole-school food environment intervention ( 7 ). Schools-based interventions are complex and therefore conducting a process evaluation (PE) is important to understand how and under what conditions programmes might work. Due to the complex nature of DAIRE and to fully understand its outcomes, we have conducted a mixed-methods process evaluation using data collected throughout the DAIRE study and following the MRC framework to evaluate DAIRE implementation, mechanisms of impact (MOI) and context ( 8 , 9 , 10 ). The objectives were: To evaluate implementation –through evaluating fidelity, acceptability, dose, reach, recruitment, retention and contamination of both the Nourish and Engage interventions. To evaluate the MOI of both the Nourish and Engage interventions. To evaluate context of the Nourish and Engage interventions and determine which contextual factors hindered and supported effective implementation of DAIRE and influence intervention outcomes. To provide scientific rationale for modifications to the Nourish and Engage interventions which will facilitate successful and effective future DAIRE rollout. Methodology DAIRE study design The DAIRE study protocol and main outcomes are published elsewhere (7). A total of 15 schools were randomized to one of the four intervention arms: i) ‘Nourish’ (n=4), ii) ‘Engage’ (n=3), iii) ‘Nourish and Engage’ (n=4) and iv) ‘Control’ (Delayed) (n=4). The specific components of the interventions are outlined in Additional File 1. Ethical approval for DAIRE was obtained from the School of Social Sciences, Education and Social Work Ethics Committee, Queen’s University Belfast (Reference number 038_1819). The significant improvements in outcomes measured in DAIRE were associated with the Nourish intervention, with a statistically significant reduction in mean Total Difficulties Score (TDS), an emotional and behavioural screening tool and one of the primary outcomes, which indicated an improvement in behaviour (11). The Nourish intervention also produced some changes in school-based dietary behaviour, which were most apparent in the 10–11 year old pupils, and improvements in understanding of food labels and knowledge of vegetables in season, whilst an increased willingness to try new foods and improved perceived cooking competence was also observed. A significant difference in Health-related Quality of Life (HRQOL) (KIDSCREEN-10) (12) of males randomised to Nourish was observed in subgroup analysis. No statistically significant difference in primary outcomes was observed in those randomised to the Engage intervention (7). DAIRE process evaluation design, sample population and data collection The DAIRE process evaluation design, key functions and interrelationships, adapted from Moore et al. is outlined in Figure 1 . Figure 1: Outline of DAIRE intervention components Sample population In total 15 schools and 983 pupils (n=495 Key Stage 1 (KS1) pupils (Year 3) and n=488 Key Stage 2 (KS) pupils (Year 7)) were recruited for the DAIRE intervention. The total number of pupils (n=494 males and n=489 females) allocated to the DAIRE interventions were as follows i) Nourish (n=189), ii) Engage (n=244), iii) Nourish and Engage (n=308) and iv) Control (Delayed) (n=242). Additionally, three Irish language schools expressed interest in participating but, as it was not feasible in terms of time or funding to translate all intervention resources in the event that these schools were allocated to one of the Engage intervention arms, these schools were not randomized but received the Nourish intervention instead. Outcome measures were translated to the Irish language and then back translated for the 3 Irish language schools to facilitate ecological validity as far as possible and enable children to complete in the appropriate language. As such, data collected from these schools were presented separately in the main paper (7). Process Evaluation Data Collection Quantitative and qualitative process evaluation data were collected throughout DAIRE in both a formal and informal manner, as shown in Table 1 . Table 1: DAIRE process evaluation data collected Data Type Quantitative Qualitative Formal NEQ (completed by teachers) ✔ ✔ ETEQ (completed by teachers) ✔ ✔ NOT (completed by study researchers) ✔ ✔ EOT (completed by study researchers) ✔ ✔ Informal (study records) Nourish implementation summary document (study researcher records) ✔ X Nourish field notes records (study researcher records) ✔ X Nourish planned Tasting Days document (study researcher records) ✔ X Emails regarding healthy snack delivery (communication received from industry partners) ✔ ✔ Mobile Petting Farm visit records (communication received from company and study researcher records) ✔ X Engage schools records (study researcher records) ✔ X Completed lessons records (teacher and study researcher records) ✔ X DAIRE feedback and quotes document (study researcher records of verbal feedback received from teachers during data collection) X ✔ Overview of Engage delivery on DAIRE researcher document (teacher and study researcher records) X ✔ DAIRE guest speakers document (study researcher records) X ✔ Records on class perceptions of the completed PE lesson (study researcher records) ✔ ✔ Email communication on school recruitment (communication received from school management) ✔ ✔ Class lists and opt-outs information (communication received from school management) ✔ X Records of numbers of baseline/end-point pupils (study researcher records) ✔ X School food environment dataset (study researcher records) ✔ ✔ Abbreviations: NEQ, Nourish Evaluation Questionnaire; ETEQ, Engage Teacher Evaluation Questionnaire; NOT, Nourish Observation Tool; EOT, Engage Observation Tool Formal Data Collection Process-Evaluation specific questionnaires were developed by the research team based on study protocol and informed by the MRC framework (13) and formed the majority of the structured formal data collection for the DAIRE PE. Specifically, two teacher evaluation questionnaires were developed: The Nourish Evaluation Questionnaire (NEQ) (Additional File 2). The Engage Teacher Evaluation Questionnaire (ETEQ) (Additional File 3). The questionnaires comprised of 18 questions and were designed to be administered to intervention schools only, with the ETEQ administered to primary school teachers and the NEQ administered to the most relevant school personnel within each school i.e., teaching staff, principal/vice principal, catering/canteen staff. Both the NEQ and ETEQ were administered at the end of the intervention period. In addition, two observational tools were also developed, which were informed by the MRC framework (13): Nourish Observation tool (NOT) (Additional File 4). Engage Observation tool (EOT) (Additional File 5). The 15-item NOT and 16-item EOT were intended for use by DAIRE researchers to observe intervention lessons and activities in the field following school permission. The questionnaires and observation tools were based on the three MRC framework elements and were designed to collect quantitative and qualitative information on: intervention delivery, appropriateness and usefulness of intervention elements, any adaptations that were made by teachers to intervention elements, whether substitute teachers were in place during intervention delivery, level of pupil engagement with the interventions, any barriers experienced during delivery, general opinions on the interventions and the presence of similar health initiatives in schools during the intervention period (13). Informal Data Collection Informal data, i.e. data collected naturally as part of the study (data not collected by the developed structured questionnaires), were also collected by DAIRE researchers at schools randomised to the intervention groups throughout the intervention period (see Table 1 ). Informal data included content and dates of relevant emails and other communications sent by school personnel, guest speakers and food industry partners regarding the Nourish and Engage interventions, and conversations and comments made during the data collection period. Follow-Up Interviews The DAIRE team planned to conduct follow-up interviews with school staff about their views and experiences of DAIRE but were unable to do so due to COVID-19-related school closures. Instead, one year after completion of the study, follow-up questionnaires (Additional File 6) were emailed to the schools which were designed to be completed by school representatives (e.g. principals, teachers and/or caterers) and collected quantitative and qualitative data on the impact of DAIRE on individual school food policies, healthy snack provision, use of DAIRE components after the intervention period, and suggestions for future implementation of DAIRE. Data Analyses Quantitative data were entered into SPSS and cleaned prior to analysis. Qualitative data were compiled, analysed and coded according to the specific element(s) of the DAIRE process evaluation framework they were relevant to. Table 2 presents the data which were used to investigate each section of the DAIRE process evaluation whilst Table 3 outlines how results are presented and statistical analyses used. Quantitative questionnaire data (NEQ and ETEQ) were analysed using SPSS statistical analysis software V 27.0. Descriptive statistics (frequencies, means, ± standard deviation and percent values) were calculated to determine the implementation – specifically fidelity, dose, reach, recruitment, retention and acceptability, MOI and context aspects of the framework ( Table 3) . Thematic analysis of qualitative data was conducted following the Braun and Clarke (14) six step framework for the implementation – specifically fidelity, dose and acceptability, MOI, and context aspects of the framework ( see Table 2 for data used ). Codes were identified inductively by a study researcher based on the frequency of key words, phrases, opinions and concepts within the data and then combined into themes ensuring that there was sufficient supporting data for each theme. All themes and codes were critically discussed and checked within the research team until a consensus was reached. Table 2: The DAIRE process evaluation framework and the data used to investigate each element DAIRE process evaluation element Data used to investigate Nourish Engage Implementation Recruitment Email communication on school recruitment Class lists and opt-out information Email communication on school recruitment Class lists and opt-out information Retention Records of numbers of baseline/end-point pupils Class lists and opt-out information Complete responses data for HRQOL and SDQ scores Records of numbers of baseline/end-point pupils Class lists and opt-out information Complete responses data for HRQOL and SDQ scores Reach Email communication on school recruitment NOT – Q7, Q8, Q9 Class lists and opt-out information Email communication on school recruitment EOT – Q6, Q7, Q8 Class lists and opt-out information Fidelity And Dose NOT – Q1, Q2, Q4, Q5, Q6, Q8, Q10, Q11, Q14, Q15 NEQ – Q1, Q2, Q3, Q4, Q18 Nourish implementation summary document Nourish school field notes records Nourish planned Tasting Days document Emails regarding healthy snack delivery Complete responses data for HRQOL and SDQ scores ETEQ – Q1, Q2, Q3, Q6, Q8, Q10 EOT –Q5, Q6, Q7, Q8, Q9. Q10, Q15, Q16 Mobile Petting Farm visits records Engage schools records Completed lessons records Complete responses data for HRQOL and SDQ scores Acceptability NOT – Q2, Q4, Q5, Q6, Q10, Q11, Q14, Q15 NEQ – Q5, Q6, Q7, Q9, Q10, Q14, Q15, Q17 DAIRE feedback and quotes document ETEQ – Q4, Q5, Q7, Q9, Q11, Q15, Q16, Q18 Overview of Engage delivery on DAIRE document DAIRE feedback and quotes document DAIRE guest speakers document Process Evaluation class copy of perceptions dataset EOT –Q5, Q6, Q7, Q8, Q9. Q10, Q15, Q16 Contamination Brennan et al. (7) main DAIRE paper: intervention study design, recruitment, randomisation and allocation. Brennan et al. (7) main DAIRE paper: intervention study design, recruitment, randomisation and allocation. Mechanisms of impact NEQ – Q3, Q5, Q6, Q7, Q9, Q10, Q14 NOT – Q6, Q10, Q14 Junkin (15) Msci paper ETEQ – Q4, Q5, Q7, Q9, Q11, Q15 EOT – Q5,Q9,Q15, Q16 Context NEQ – Q3, Q11, Q12, Q13, Q16 School food environment dataset Nourish implementation summary document Complete responses data for HRQOL and SDQ scores ETEQ – Q3, Q6, Q10, Q12, Q13, Q14 Engage schools records School food environment dataset Completed lessons records Complete responses data for HRQOL and SDQ scores Abbreviations: HRQOL, Health-related Quality of Life; SDQ, Strengths and Difficulties; NEQ, Nourish Evaluation Questionnaire; ETEQ, Engage Teacher Evaluation Questionnaire; NOT, Nourish Observation Tool; EOT, Engage Observation Tool Table 3: How each DAIRE process evaluation element was investigated DAIRE process evaluation element and MRC definition (16) How each element was investigated Recruitment Expressed as the total number of pupils in each intervention arm and DAIRE as a whole. Retention Expressed as the mean % of opt-out pupils, as well as the % completion rate of complete (both baseline and endpoint) data responses for the KIDSCREEN-10 questionnaire and Strength and Difficulties (SDQ) questionnaire. Reach ‘the extent to which a target audience comes into contact with the intervention’ Using recruitment and retention data to determine the extent to which primary school children aged 6-7 and 10-11 years in the North West region of NI came into contact with DAIRE. Fidelity ‘the consistency of what was implemented with the planned intervention’ Nourish fidelity was determined the % of Nourish elements delivered and made available to schools, and the % of Nourish elements delivered in each individual school Engage fidelity was determined as the % of Engage elements made available to schools, the mean % of topic 1, topic 2 and topic 3 delivered in Engage schools, and the mean % of guest speakers, visits and activities implemented in schools Thematic analysis of informal data sources outlined in Table 2 Dose ‘the quantity of intervention delivered’ Nourish dose was expressed as the mean % of Nourish elements delivered in schools Engage dose was expressed in two ways: A) The % of schools which achieved Core Engage delivery B) The mean % of engage topics, guest speakers, food industry visits and activities (out of 26 elements) delivered in schools Thematic analysis of informal data sources outlined in Table 2 Acceptability Participant responses to Likert-scale questions in the NEQ and ETEQ were coded on a 5-point scale ranging from 1 ‘Strongly Agree’ to 5 ‘Strongly Disagree’. Mean score, standard deviation, frequencies and %’s were calculated and expressed, with a lower score indicating higher acceptability Thematic analysis of informal data sources outlined in Table 2 Contamination ‘The likelihood of control group participants being exposed to the active intervention’ Examining the likelihood of DAIRE control group participants being exposed to the Nourish and Engage interventions through examining the DAIRE intervention study design, recruitment, randomisation and allocation. Mechanism of Impact ‘How did the delivered intervention produce change?’ Frequencies and %’s were calculated with regards relevant NEQ and ETEQ questions on pupil reaction to the interventions and which elements were most useful and appropriate (see Table 2 ). Thematic analysis of informal data sources outlined in Table 2 Context ‘Factors external to the intervention which may influence implementation, or whether MOI act as intended’ Frequencies and %’s were calculated with regards both the schools and teachers at classroom level who reported barriers, the presence of similar health initiatives and if substitute teachers were in place during intervention delivery Thematic analysis of informal data sources outlined in Table 2 Results In total, 51.6% (n=16) of the NEQ and 42.3% (n=11) of the ETEQ were returned by teachers and 9.7% (n=3) of the NOT and 9.1% (n=1) of the EOT were completed by the research team. Implementation – Recruitment The DAIRE intervention recruitment process, which was completed over a 6-week period (Jan-Feb 2019) and resulted in 15 randomised schools, is available in Additional File 7. Retention A 100% retention rate was observed at both school and pupil level, with no schools (n=15) dropping out, or pupils withdrawing consent once the DAIRE intervention began. Only five schools provided information regarding individual numbers of pupils who opted-out (data on n=128/983 pupils); indicative of 13% of pupils based on this subset. Retention was also determined in terms of the number of paired baseline and end-point responses for primary outcomes within the 15 randomised DAIRE schools (n=983 pupils). The rate of completion for the pupil- focused Strength and Difficulties questionnaire, completed by teachers, was much lower (54.2%; n=533) than the pupil-completed questionnaire for the primary outcome, KIDSCREEN-10 questionnaire, with 79.7% (n=783) completing both at baseline and end-point (11 and 12). Reach It was not feasible to assess the exact % of primary school children aged 6-7 and 10-11 years in the NW region of NI that DAIRE reached, as there are no publicly available data on the number of pupils by age group in the region. However, in total, DAIRE reached 983 primary school children (n=495 aged 6-7 and n=488 aged 10-11 years) and, considering a total of 142 mainstream primary schools in the NW region of NI were contacted, with an approach aiming to include schools in both urban and rural locations, both faith and non-faith based schools and those where English was not used as first language (Irish language schools), DAIRE recruited 10.6% (n=15 randomised) of possible mainstream primary schools within this region. Fidelity and Dose Nourish Intervention A delayed DAIRE intervention start date, in March rather than February 2019, resulted in late delivery of some Nourish intervention elements (May 2019) and the closure of schools for the summer recess in June 2019, is likely to have affected Nourish implementation and, as a result, observed primary and secondary outcomes. In total, 100% (n=8) of Nourish schools received intervention elements and resources to enable complete intervention delivery. An additional option to hold a school food event sponsored by food industry partners was offered to only n=3 Nourish randomised schools due to practicalities and n=2 availed of this opportunity. Table 4 highlights that, on average, Nourish schools (n=8) implemented 61.4% of the Nourish intervention, (range of 28.6% school Q to 85.7% school G). The most delivered Nourish element was healthy snack provision, which 100% (n=8) of Nourish schools availed of. A total of 75% (n=6) and 87.5% (n=7) of schools utilised equipment to enhance the school environment and presentation of food respectively, and 50% (n=4) of schools utilised cookery equipment and recipes. A high percentage of 87.5% (n=7) of schools attended Tasting Days. One school utilised the sensory education tool (n=1, 12.5%) and one (12.5%) availed of the opportunity to optimize their school food policy by booking an individual session with a member of the DAIRE research team. As this was low, all schools (100%) received a general document with advice relating to school food policies. Table 4: Summary of Nourish intervention elements implemented School Code Nourish elements Nourish elements delivered at individual school level n ( %) Healthy snack provision Enhancement of dining area Enhanced food presentation Cookery equipment and recipes Sensory education Optimise school food policies Tasting day School food event* E ✔ ✔ ✔ ✔ X X ✔ N/A 5(71.4) F ✔ ✔ ✔ ✔ X X ✔ N/A 5(71.4) G ✔ ✔ X ✔ ✔ ✔ ✔ N/A 6(85.7) J ✔ ✔ X ✔ X X ✔ ✔ 5(62.5) L ✔ X ✔ X X X ✔ ✔ 4(50) P ✔ ✔ ✔ X X X ✔ X 4(50) Q ✔ ✔ X X X X X N/A 2(28.6) R ✔ X ✔ X X X ✔ N/A 3(42.9) Nourish schools who delivered element (n=8) 8(100) 6(75) 7(87.5) 4(50) 1(12.5) 1(12.5) 7(87.5) 2(66.7) Mean Dose of Nourish elements delivered in schools (%): 61.4 Mean (SD) number of Nourish elements delivered in schools: 4.3 (1.28) * Only 2 schools offered this option. Note: N/A for school food event as schools not offered option to partake Engage Intervention With regards to Engage, 100% (n=7) of Engage schools received intervention materials to enable complete intervention delivery. Following early teacher feedback on the large volume of Engage content, DAIRE study researchers agreed with the Engage partner schools that a core minimum Engage delivery of five lessons with associated activities and one talk from a guest speaker should be completed for the intervention. Notably, 100% (n=7) of Engage schools implemented this minimum. However, as shown in Table 5 , on average, Engage schools (n=7) implemented 50% of the original full intervention material, as outlined in Additional Files 8, 9 and 10. Table 5: Summary of Engage elements implemented in schools Engage schools (n=7) Completed 5 lessons with associated activities Completed 1 talk from a guest speaker Mean core minimum Engage delivered n (%) Engage elements delivered per school (n=26 in total) n (%) Mean dose of Engage elements delivered in schools (%) Mean (SD) number of Engage elements delivered in schools (n=26) C ✔ ✔ 7(100) 13(50) 50 13 (1.73) D ✔ ✔ 12 (46.1) O ✔ ✔ 14(53.8) G ✔ ✔ 11(42.3) L ✔ ✔ 15(57.7) P ✔ ✔ 15(57.7) R ✔ ✔ 11(42.3) Acceptability Results of Likert-scale questions ( Table 6 ) revealed high acceptability of the Nourish and Engage interventions by teachers within a NI primary school setting. Table 6: Teacher Acceptability of the Nourish and Engage intervention as reported within the NEQ and ETEQ Part A) Nourish Key Stage Strongly Agree Agree Neither Agree nor Disagree Disagree Strongly Disagree Mean Score (SD) Q5 Nourish resources, food items and activities useful and appropriate (n=16) N/A 14 (87.5) 2 (12.5) 0(0) 0(0) 0(0) 1.1(0.34) Q6 Delivery of Nourish elements (snacks, canteen decorations) organised and easy to manage (n=16) 9(56.3) 6(37.5) 1(6.3) 0(0) 0(0) 1.5(0.51) Q7 Organisation of Tasting Days adequate (n=12) 9 (75) 2(16.7) 1(8.3) 0(0) 0(0) 1.3(0.4) Q9 Pupil reaction to the Nourish intervention elements (e.g. snacks. Canteen decorations, food presentation, Tasting Days) was generally positive (n=16) 15 (93.8) 1 (6.3) 0(0) 0(0) 0(0) 1(0.25) Q10 Nourish Tasting were a positive experience (n=14) 11(78.6) 3(21.4) 0(0) 0(0) 0(0) 1.2(0.43) Part B) Engage Q4 Engage Lesson plans useful and appropriate for year group (n=11) KS1 n=9 3(33.3) 6(66.7) 0(0) 0(0) 0(0) 1.7(0.5) KS2 n=2 1(50) 1(50) 0(0) 0(0) 0(0) 1.5(0.71) Q5 Engage Guide timings within lesson plans used accurate and appropriate (n=10) KS1 n=8 3(37.5) 4(50) 1(12.5) 0(0) 0(0) 1.8(0.71) KS2 n=2 0(0) 2(100) 0(0) 0(0) 0(0) 2(0) Q7 Available resources within the Farm to Fork, Pleasure on a Plate and Food Futures topics appropriate and useful for year group (n=10) KS1 n=8 2(25) 6(75) 0(0) 0(0) 0(0) 1.8(0.46) KS2 n=2 1(50) 1(50) 0(0) 0(0) 0(0) 1.5(0.71) Q9 Pupil reaction to Engage lessons was positive (n=11) KS1 n=9 6(66.7) 2(22.2) 1(11.1) 0(0) 0(0) 1.4(0.73) KS2 n=2 1(50) 1(50) 0(0) 0(0) 0(0) 1.5(0.71) Q11 Engage speakers or visits useful and appropriate (n=11) KS1 n=9 5(55.6) 4(44.4) 0(0) 0(0) 0(0) 1.4(0.53) KS2 n=2 2(100) 0(0) 0(0) 0(0) 0(0) 1(0) Nourish data reported as n (%) of participant (n max = 16) responses to the above statements Engage data reported as n (%) of participant (nmax=11) responses to the above statements NEQ data completed by teaching staff, principal/vice principal or reception staff – i.e., school staff Thematic analysis of Nourish and Engage qualitative data supports these findings as follows ( Table 7 ). Within the NEQ, teachers reported that healthy snack provision was the most valuable element of the Nourish intervention and that Nourish had a positive effect by encouraging children to try new food items, with even ‘fussy’ children consuming the snacks after observing their peers. Furthermore, teachers reported that trips to C1 and C2 were highly enjoyable and that Tasting Days encouraged children to try new foods and were delivered in an interactive way which instilled confidence and a sense of responsibility in children. The Nourish theme of ‘Useful canteen decorations’ emerged, as most teachers reported that delivery of canteen decorations (e.g. posters, bunting and tablecloths) was prompt and effortless and decorations were a useful addition to the school. Table 7: Thematic analysis of qualitative Nourish and Engage intervention data Part A) Nourish Themes Codes Illustrative Quotes Pupils enjoyed healthy snack provision Children enjoyed snacks Encouraged tasting of new foods which children had not tried previous Hassle free prompt snack delivery Easy access packaging of snacks Sense of independence for children Time-consuming to butter toast – but worth it “The children really enjoyed their snack this week. It might interest you to know that, for a few, it was their first time tasting wheaten bread! It all went down very well” [School E P7 teacher] “Yes, the delivery took place promptly each Thursday and more than enough food for pupils provided” [School E principal] “They loved having their bread toasted and the independence of buttering their own/preparing their own snack.” [School J teacher] “When classroom assistant was there-easy to toast/butter etc. But very time consuming-lovely as a treat once a week” [School G teacher] Well-organised and engaging tasting days Well-organised Children enjoyed and engaged Encouraged to try new food items Sense of responsibility Age appropriate All children’s diets catered for “Highly organized. Someone to meet us off the bus. Didn’t have to think of anything. Children were engaged throughout. Very worthwhile experience” [School G teaching staff] · “The experiences gave the children a chance to prepare food together e.g. making sandwiches. It gave them a sense of responsibility.” [School G teacher] · “Children shown video from FIP4, children all screamed ‘ahh’ when chicks were on screen. MP staff told children they had lots of different flavours of chicken with them today but that they ‘mixed them up’ so they needed pupils help to identify flavours. Children tried different flavours and had to guess e.g. plain chicken, BBQ, Sweet Chilli, Tikka Masala. Pupils very excited and shouted out answers/guesses for every flavour. Lots of hands up/interaction. Many pupils told me this was their favourite station” [DAIRE Research team member] Useful canteen decorations Easy and prompt delivery Equipment and good addition to school “The equipment provided to the canteen has been most welcome and put to immediate use”. [School E principal] “Delivery of canteen equipment was hassle free” [School E principal] “… The canteen decorations will be an excellent addition to our canteen in the new school year and staff were delighted to receive them”. [School R teacher] Part B) Engage Enjoyable Engage topics, lessons and resources · Children enjoyed and engaged with interactive lessons and resources: videos, games, stories, songs, physical education lesson · Accessible resources · Age-appropriate · “Age appropriate, pupils engaged and enjoyed, informative [School D P3 teacher] · “I liked that the resources were interactive and all links for online resources were easily accessible. The children enjoyed the story books and songs” [School O P3 teacher] · “The videos and lesson plans were very informative and provided great introductions for each area and generated good discussions too!” [School G P3 teacher] · “Fantastic enthusiasm-particularly Animal Welfare and Johnny Loves Milk. Children loved their PE lesson and stories from the Powerpoint” [School O P7 teacher] · “Lots of excitement, P3 kids very engaged and excited, salmon and jellyfish game, all pupils responded well” [DAIRE research team observing physical education lesson] Questionable age-appropriateness for P3 children · Attention span of younger children · Lessons too detailed and advanced · “Some videos were a little long for P3 children. The ‘Right Royal Fishy Tale’ book was also a bit too long to hold my P3s attention throughout although they did love the storyline” [School R P3 teacher] · “The resources and activities were appropriate and useful…we found the Food Futures element harder to deliver as KS1 pupils aren’t as influenced by marketing etc…some lessons needed to be simplified/adapted” – [School G P3 teacher] Engaging guest speakers, trips and visits · Children enjoyed and engaged · Age-appropriate · Informative · Possible that money spent on trips was not worthwhile ( Note: only in one school ) “All speakers were knowledgeable on their subjects and engaged the children” [School C P7 teacher] · “Really engaged children-appropriate to age group. Great resources and follow up activities. Great to have a specialist to talk to children” [School G P3 teacher] · “The Farm was amazing. The children thoroughly loved it. The staff engaged so well with the children” [School D Principal] · “Address given incorrect..10 minute visit…I just feel that the money spent on buses and the time spent travelling was a waste of funds which could have been spent elsewhere.” [School P Teacher] Teachers reported that interactive lessons and resources such as videos, games and the practical physical activity (Physical Education) lesson were the most popular aspects of Engage and that the Animal Welfare and Johnny Loves Milk lessons were particularly favoured. Some concerns were raised in relation to lessons being too advanced and detailed when considering the attention span of younger children. With respect to the Engage theme of, ‘Engaging guest speakers, trips and visits’, teachers emphasized that children enjoyed these Engage elements, finding them extremely informative and useful. One theme which emerged consistently within both Nourish and Engage qualitative data was that the DAIRE intervention should be implemented across a full academic year. Most teachers commented on timing and planning pressures and this, combined with the fact that DAIRE did not begin until late into the second academic term, meant that delivery was rushed. “There is a LOT of content. Need a whole school year to develop properly and do all lessons” [School P ‘Nourish and Engage’ P3 teacher] Contamination No formal data were collected in relation to contamination but it is unlikely that contamination influenced the intervention and outcome data collection as a result of study design and randomization (Additional File 11). Mechanisms of Impact As interviews with pupils were not conducted, it was not possible to explore potential mediators of behaviour change or unanticipated pathways within this process evaluation. However, thematic analysis of qualitative teacher responses within the NEQ and ETEQ allowed insight into pupil reaction and engagement with the interventions and exploration of possible DAIRE MOI.Two possible MOIs in relation to the Nourish intervention were identified ( Table 8 ): Social learning Experimental Learning (hands-on approach) Most teachers reported that social learning and peer influence was key to healthy snack consumption, with pupils being more willing to try new foods and opting to consume the Nourish healthy snacks once they observed their peers doing so. This may imply that Nourish elements such as Tasting Days and healthy snack provision may have produced the significant changes observed in the DAIRE trial in terms of increased willingness to try new foods through pupil bonding and shared learning. The Nourish intervention is also likely to have produced change by increasing pupils’ knowledge about food and healthy food options through fun-based learning and experiences. Teachers commented in the NEQ that preparing healthy snacks and feeding back product preferences during Tasting Days influenced children’s awareness of healthy food options and helped instil a sense of responsibility and independence in children regarding their food intake and dietary choices. MOI for Engage were explored as, although no statistical differences were observed regarding primary outcomes, teachers reported the benefits of Engage and commented on how it should be integrated into the school curriculum. Thematic analysis identified two possible MOI in relation to the Engage intervention ( Table 8 ): 1. Interactive engage content 2. Real life connections Teachers commented that the Engage topic and lesson content was interactive, stimulating and engaging for children and encouraged class discussions. The Engage intervention also allowed pupils to establish real life connections. Relating lessons to real life i.e., Animal Welfare lesson to the children’s pets, cooking a meal together, attending the pet farm and listening to guest speakers brought the Engage topic to life. Table 8: Mechanisms of change uncovered from NEQ and ETEQ data Part A) Nourish Mechanism of impact How it worked Illustrative Quotes Social Learning Peer influence Pupils imitate pupils Class discussions Preparing food together “When given the wheaten bread/brown bread first a number of the children had never had before and didn’t try it but eventually most of them were eating it and really enjoying it. As often as possible we had the snack along with the P7-great peer tutoring opportunities.” [School L teacher] “The children became more independent at preparing their snacks, helping each other etc. and looked forward to the days snacks” [School J teaching staff] “The children looked forward to their snacks; even tasting wheaten bread for the first time and enjoying it! They enjoyed having toast in the classroom.. They shared out their fruit with each other if they didn’t fancy eating some of them.” [School G teacher] Fun-based learning Increased knowledge of healthy food Sense of independence and responsibility Children involved in decision making “The healthy snacks encouraged healthy eating. The Tasting Day taught the children a lot and again encouraged healthy eating.” [School R teacher] “Children loved having the choice of their own snack. They loved having their bread toasted and the independence of preparing their own snack.” [School J teaching staff] “The experiences gave the children a chance to prepare food together e.g. making sandwiches. It gave them a sense of responsibility.” [School G teacher – Regarding Tasting Day at C1] Part B) Engage Interactive engage content Class discussions Group work Interactive lessons – stories, songs, videos “Really engaged children-appropriate to age group. Great resources and follow up activities. Great to have a specialist to talk to children.” [School G P3 teacher – Regarding guest speakers] “Children loved planning their own menus and enjoyed presenting their ideas to the class. Lessons allowed for lots of group work and discussion. Everyone was included – re Food Futures: Restaurant lesson” [School L P3 teacher] “Fantastic enthusiasm-particularly Animal Welfare and Johnny Loves Milk. Children loved discussions/debates. Children loved their PE lesson and stories from the PowerPoint” [School O P7 teacher] Real life connections Relate to real life scenarios Brought DAIRE to life Memorable lessons and visits “Children really liked making their own book as part of the ‘Food Scribblers’ lesson. They are enjoying the Food Futures lessons and are excited to cook the meal chosen by the class. The visit of the travelling farm was one of their favourite parts” [School R P3 teacher] “Some children were able to contribute real life experiences due to family farm links” [School L P3 teacher] “The children loved the Animal Welfare lesson and related it to how they look after their pets at home!” [School R P3 teacher] Context Teachers from 50% (n=4) of Nourish schools and teachers from 71.4% (n=5) of Engage schools reported experiencing barriers during intervention delivery. Thematic analysis of NEQ and ETEQ qualitative responses revealed that time was the biggest DAIRE barrier which, in turn is likely to have influenced the time to induce pupil change and, ultimately, the change in primary and secondary outcomes observed. Teachers had to give priority to delivering the national curriculum and other school priorities and, as such, they reported shortening lessons or not completing lessons due to time constraints: “Time was a major issue. With everything else needing to be taught it was difficult to fit it in” [School C Engage P3 teacher] Teachers also reported that DAIRE should be planned well in advance of the school year to enable complete implementation. Overall PE findings detail the main barrier to DAIRE intervention implementation was time, which in turn was likely to have influenced the time to induce pupil change and, ultimately, the change in primary outcomes observed. However findings on fidelity and dose, acceptability and MOI, suggested that guest speakers, the Mobile Petting Farm, healthy snack provision and Tasting Days were the most popular elements and the ones that had a notable positive influence. Such elements would be costly, therefore the removal of the cost barrier to DAIRE may be considered a facilitating factor. These findings are notable, as such factors must be retained and replicated in future delivery. The follow-up questionnaire designed for school representatives (principals, teachers and/or caterers) were sent to all participating primary schools approximately 1 year after the end of the interventions and responses were received by 5 schools, giving a response rate of 33% (5 principals, 6 teachers and 3 caterers). Responses received were generally very positive and highlighted particularly beneficial aspects, including the popularity of the healthy snack provision, enhancement of healthy eating polices and introduction of a sensory eating component, also identifying time constraints as a barrier to implementation. Discussion DAIRE findings reported by Brennan et al., ( 7 ) indicated that the Nourish food environment intervention produced more positive changes in emotional and behavioural wellbeing, food knowledge, cooking competence and dietary intake than the Engage food-education intervention in primary school children in an economically disadvantaged area in Northern Ireland. The aim of this study was to conduct a process evaluation to help elucidate why the Nourish intervention was more effective than the Engage intervention and inform any modifications for successful future UK-wide DAIRE rollout. DAIRE had a 100% retention rate at both school and pupil-level which appears higher than seen in other school-based dietary interventions ( 17 , 18 ), although retention rates are often not reported in school-based diet/food environment process evaluations. Process evaluation results, along with teachers’ follow-up feedback, indicated high levels of acceptability and engagement with both the Nourish and Engage interventions and these two factors have previously been identified as integral to intervention success ( 19 , 20 , 21 ). Methods used to determine acceptability and contamination vary widely across the PE literature, so it is difficult to directly compare these elements; however DAIRE acceptability and risk of contamination also appears comparable with other process evaluation literature with no issues were identified for either element. Findings on quality (fidelity) and quantity (dose) of DAIRE implementation revealed that Nourish schools implemented a higher mean intervention dose in comparison with Engage schools which may help explain its effectiveness when compared with Engage in terms of the primary and secondary outcomes. DAIRE implementation levels are comparable with those reported within other school-based interventions targeting fruit and vegetable consumption, physical activity, dietary behaviour and obesity prevention (range of 30–97% reported) ( 17 , 18 , 22 , 23 , 24 , 25 , 26 ). Furthermore, although teachers reported making adaptations to both interventions, largely to reduce amount of content due to time pressures, it is difficult to get a sense of the extent of adaptations from the data collected. This is notable as Inchley et al., ( 27 ) reported that teachers feeling empowered to adapt interventions can enhance intervention effectiveness. In contrast, however, adaptations to Engage related to lesson reduction, may have influenced fidelity and could possibly have contributed to the lack of change produced in those randomised to the Engage intervention. Furthermore, it was not possible to consider fidelity of training materials given to teachers as part of DAIRE but would be of interest to explore this further in future in terms of more comprehensive teacher training in relation to intervention delivery. PE results revealed the intervention elements most implemented required the least teacher effort. These results are in-line with process evaluation results of the Child and Adolescent Trial for Cardiovascular Health and High 5 school-based interventions, whereby more time-consuming activities were implemented less frequently by teachers in the classroom ( 26 , 28 ). A systematic review of the implementation of 24 school-based fruit and vegetable distribution interventions highlights the need for detailed implementation guidelines and training workshops for teachers to ensure high intervention fidelity ( 19 , 29 ). The Engage resources in DAIRE included a video aimed at teachers, but more detailed guidance/training, alongside more time to plan how to introduce the programme into their classroom are likely to be of value. There were also varying levels of teacher engagement in relation to outcome assessment, although this is distinct from the intervention delivery. In contrast, PE findings regarding high pupil questionnaire response rate demonstrate the high level of engagement in relation to data collection in children which will be encouraging in relation to any future DAIRE rollout. Ultimately, stronger engagement with outcomes assessment could have resulted in more reliable conclusions regarding both primary and secondary DAIRE outcomes. Educational attainment data were also requested from participating schools but the limited data received from a small number of schools (n = 5) were variable in format and did not allow for formal analysis, which highlights the need for standardisation of data collection methods in any future evaluation. Four possible MOI: social learning and fun-based learning in relation to Nourish, interactive engaging content, and real-life connections in relation to Engage, were identified from process evaluation findings that help to explain how the Nourish intervention produced change. Fidelity, dose and acceptability results indicated that Nourish healthy snacks and Tasting Days, and Engage lessons involving story books, songs and process evaluation lessons, as well as Guest Speakers and the Mobile Petting Farm were the key DAIRE intervention elements. The majority of these identified key elements were delivered as part of the Nourish intervention specifically, which may explain its effectiveness compared with Engage in relation to the trial outcomes. These findings are comparable to process evaluation findings from other school-based interventions including Project Tomato, High 5 and EMPOWER, whereby the most popular pupil activities were interactive ( 18 , 28 , 30 ). In terms of ensuring intervention effectiveness and successful future UK-wide rollout, process evaluation findings suggest that an overall focus should be placed on retaining the key MOI, and ensuring DAIRE is interactive and easy to implement for teachers. It is evident from process evaluation results that lack of time was a key contextual barrier influencing DAIRE implementation and was most reported in relation to Engage, which relied more on teacher delivery. This finding is consistent with process evaluation findings from Christian et al. ( 31 ) regarding Project Tomato (n = 311 children aged 7 years in 24 schools) and Bere et al. ( 32 ) regarding Fruit and Vegetables Make the Marks (n = 369 children, mean age 11.9 years, in 9 schools); whereby low implementation levels and little difference in children’s dietary intake was observed in schools as a result of intervention materials requiring too much preparation time. Process evaluation identified that teachers felt that DAIRE should be implemented across the full academic year and be integrated into the school curriculum. Similarly, previous process evaluation studies of the We Act and the Active for Life Year 5 primary school-based interventions, reported integration of intervention content into the curriculum as a possibility to improve implementation and outcomes ( 19 , 33 ). DAIRE Engage intervention content was mapped to the NI curriculum, but as already discussed, planning time for teachers is likely to have been limited so this should be built into any further rollout. Originally it was planned for Nourish to include more of a focus on canteens and food served rather than food presentation, however, procurement regulations within schools and the need to adhere to food standards precluded this within the timeframe. It is likely that influencing procurement chains within school systems would be challenging as contracts are typically already in place so it is important to be aware of these potential challenges when designing future studies. Catering staff feedback suggested issues with limited time to prepare food and time allocated for pupils to eat the food, therefore these considerations need to be built into any rollout of the programme. Although statistically significant effects on primary outcomes were not demonstrated by Engage, it may have been due to its more limited implementation, as although 100% of Engage schools delivered core elements of Engage, mean delivery was 50% of the overall engage intervention elements, largely due to teacher time pressures. Furthermore, the research aimed to conduct with trial with ecological validity, where possible, but it was not feasible in terms of time and funding to translate all Engage intervention resources in the event Irish language schools were randomized to the Engage arm of the trial and this may be an important consideration in any future roll-out in regions where different languages are necessary. However, in order to achieve a whole-school approach and its prospective benefits to children’s diet quality and nutritional knowledge, the Engage education intervention should be considered for retention in any future DAIRE rollout. This may induce a sense of community amongst pupils, ensure consistency in the healthy eating messages both within and outside of the classroom; key here is making the lessons fun and memorable for participating children, whilst also extending their knowledge. This process evaluation has several strengths. It followed the recently updated MRC guidance and employed a comprehensive mixed-methods approach to evaluate all three framework elements. Due to prior planning, process-evaluation-specific tools and questionnaires were developed and used throughout the DAIRE intervention. Also, due to the large volume of DAIRE PE data collected, merging of data sources occurred, after discussion with the research team, to enable the most effective interpretation and use of data collected in terms of data quality and relevance for each aspect of process evaluation. A number of factors reduced the likelihood of contamination of control participants in this trial, including whole school rather than class randomization and adequate training and experience of the DAIRE research team when carrying out data collection in control schools. Therefore, it is unlikely that contamination influenced any of the DAIRE primary or secondary outcomes observed (Additional File 10). In terms of limitations, data collected from teachers that completed the process evaluation questionnaires may not be representative of all teachers who were involved in the implementation of DAIRE. Furthermore, there is potential for bias in data collection as some of the researchers involved in main study outcome data collection were involved in process evaluation data collection. The researcher leading the initial process evaluation analysis was not involved in the DAIRE trial in any way, but researchers involved in the trial reviewed and commented on the final process evaluation manuscript. Additionally, no direct pupil feedback regarding the DAIRE intervention exists. Planned follow-up teacher phone calls and interviews were not possible due to the COVID-19 pandemic, therefore no data on DAIRE intervention sustainability were collected and triangulation of DAIRE PE results was not possible. In addition to this, the majority of school principals did not respond to requests for the DAIRE research team to attend to conduct Nourish and Engage process evaluation-related observations, therefore observations were limited. Within this process evaluation, data on mediating and moderating factors were not collected and the process evaluation findings did not elicit, for example, understanding of why health-related quality of life significantly improved in males randomised to Nourish significantly compared with those who did not receive Nourish in subgroup analyses ( 12 ). Therefore, future work exploring mediating and moderating factors may be informative in terms of interpreting these findings. Finally, process evaluation was completed following the main DAIRE study outcomes being published; thus biased interpretation is possible. However, as initial process evaluation analysis was undertaken independently by a researcher who was not directly involved with the DAIRE implementation and in-person data collection, the likelihood of this is reduced. Gaps for future DAIRE research identified from this process evaluation include: sourcing a sustainable funding and resourcing mechanism for future rollout, including a range of funding models and the role of the private sector. Incorporation of a ‘family’ and/or community aspect to the interventions to fully achieve a whole-school approach should also be considered. Overall, it is likely that DAIRE intervention success is generalisable to UK-wide primary schools and beyond, due to the comparable structures within the primary school education system, therefore process evaluation findings can help to inform the plan and design of future similar effective interventions. Conclusion In conclusion, the DAIRE PE yielded several important findings related to the implementation, MOI and contextual factors influencing DAIRE intervention effectiveness and outcomes and helped to elucidate why Nourish produced more positive changes in outcomes than the Engage intervention. The most effective elements of the interventions which should be maintained in any future rollout include provision of interactive and engaging intervention elements at no financial cost to the school. Findings also identified suggestions for improvement including provision of increased teacher training, support and planning time, content reduction to facilitate easy integration into the existing school curriculum, and implementation across the full academic year. Abbreviations MOI: Mechanisms of impact MRC: Medical Research Council HRQOL: Health-related Quality of Life NEQ: Nourish Evaluation Questionnaire ETEQ: Engage Teacher Evaluation Questionnaire NOT: Nourish Observation Tool EOT: Engage Observation Tool SDQ: Strength and Difficulties KS: Key Stage Declarations Ethics approval and consent to participate Ethical approval for the main DAIRE trial was obtained from The School of Social Sciences, Education and Social Work Ethics Committee, Queen’s University Belfast (Reference number 038_1819). Parental informed consent was obtained for all pupils who participated in this trial. Consent for Publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The main trial was funded by Agri-Food Quest Competence Centre, funded by Invest Northern Ireland. The study funder had no role in the study design, collection, analysis or interpretation of the data and had no role in writing the manuscript. No further funding was required to complete the process evaluation. Authors’ contributions NA drafted the manuscript, with input from SFB and JVW. All authors read and approved the final manuscript. In relation to the Daire trial, JVW was the Chief Investigator, formulated the research question, designed the trial and directed the research activities. MD, DMC, MCMK, PMC, CE, RFH, LD, NEOC, and CRC advised on aspects of the study design and implementation. SFB, SEM and FL were involved in intervention delivery and data collection. All author(s) and industry partners that were involved in delivery of the DAIRE trial read and approved the final manuscript. Acknowledgements The authors wish to thank the pupils, principals, teachers and caterers from all the schools that participated in the project or were involved in the development of the resources. The authors are grateful for the support received from the local food industry partners, visiting experts from Queen’s University Belfast and personnel from Further Education Colleges during the implementation of the trial. The authors would also like to thank Mrs. Clare Jess for her assistance with the administration of the trial. References Gaziano JM. When should heart disease prevention begin? N Engl J Med. 1998;338(23):1690–2. Lake AA, Mathers JC, Rugg-Gunn AJ, Adamson AJ. Longitudinal change in food habits between adolescence (11–12 years) and adulthood (32–33 years): the ASH30 Study. J Public Health. 2006;28(1):10–6. Popkin BM, Gordon-Larsen P. The nutrition transition: worldwide obesity dynamics and their determinants. International Journal of Obesity and Related Metabolic Disorders [Online]. 2004;28(Suppl 3):S2-9. Available at: https://www.nature.com/articles/0802804 [Accessed: December 13th 2021]. Woodside JV, Adamson A, Spence S, Baker T, McKinley MC. Opportunities for intervention and innovation in school food within UK schools. Public Health Nutr. 2021;24(8):2313–7. Weichselbaum E, Buttriss JL. Diet, nutrition and school children: an update. Nutr Bull. 2014;39(1):9–73. Wang D, Stewart D. The implementation and effectiveness of school-based nutrition promotion programmes using a health-promoting schools approach: a systematic review. Public Health Nutr. 2013;16(6):1082–100. Brennan SF, Lavelle F, Moore SE, Dean M, McKinley MC, McCole P, et al. Food environment intervention improves food knowledge, wellbeing and dietary habits in primary school children: Project Daire, a randomised-controlled, factorial design cluster trial. Int J Behav Nutr Phys Activity. 2021;18(1):23. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance, British Medical Journal, 374, n2061. 2021;473:n2061. Available at: http://dx.doi.org/10.1136/bmj.n 2061 [Accessed: 8th October 2021]. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350:h1258. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322–7. Goodman R. The Strengths and Difficulties Questionnaire: A Research Note. J Child Psychol Psychiatry. 1997;38(5):581–6. Ravens-Sieberer U, Gosch A, Erhart M, von Rueden U, Nickel J, Kurth B-M, et al. The KIDSCREEN Group Europe. The KIDSCREEN Questionnaires. Quality of Life Questionnaires for Children and Adolescents. Volume 49525. Lengerich: Pabst Science Publishers; 2006. [Available from: www.kidscreen.org.]. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance, British Medical Journal, 374, n2061. 2021;473:n2061. Available at: http://dx.doi.org/10.1136/bmj.n 2061 [Accessed: 8th October 2021]. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. Junkin A. What is the association between school based nutrition interventions and children’s health beliefs: An analysis of secondary data from the DAIRE project [MPH thesis]. Belfast: Queen’s University Belfast; 2021. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350:h1258. Singh AS, Chinapaw MJM, Brug J, Van Mechelen W. Process evaluation of a school-based weight gain prevention program: the Dutch Obesity Intervention in Teenagers (DOiT). Health Educ Res. 2009;24(5):772–7. Lytle LA, Murray DM, Perry CL, Story M, Birnbaum AS, Kubik MY, et al. School-based approaches to affect adolescents' diets: results from the TEENS study. Health Educ Behav. 2004;31(2):270–87. Jago R, Rawlins E, Kipping RR, Wells S, Chittleborough C, Peters TJ, et al. Lessons learned from the AFLY5 RCT process evaluation: implications for the design of physical activity and nutrition interventions in schools. BMC Public Health. 2015;15(1):946. Campbell R, Rawlins E, Wells S, Kipping RR, Chittleborough CR, Peters TJ, et al. Intervention fidelity in a school-based diet and physical activity intervention in the UK: Active for Life Year 5. Int J Behav Nutr Phys Activity. 2015;12(1):141. Mathews LB, Moodie MM, Simmons AM, Swinburn BA. The process evaluation of It's Your Move! an Australian adolescent community-based obesity prevention project. BMC Public Health. 2010;10(1):448. Davis M, Baranowski T, Resnicow K, Baranowski J, Doyle C, Smith M, et al. Gimme 5 fruit and vegetables for fun and health: process evaluation. Health Educ Behav. 2000;27(2):167–76. Steckler A, Ethelbah B, Martin CJ, Stewart D, Pardilla M, Gittelsohn J, et al. Pathways process evaluation results: a school-based prevention trial to promote healthful diet and physical activity in American Indian third, fourth, and fifth grade students. Prev Med. 2003;37(6):80–S90. Baranowski T, Davis M, Resnicow K, Baranowski J, Doyle C, Lin LS, et al. Gimme 5 fruit, juice, and vegetables for fun and health: outcome evaluation. Health Educ Behav. 2000;27(1):96–111. Perry CL, Bishop DB, Taylor G, Murray DM, Mays RW, Dudovitz BS, et al. Changing fruit and vegetable consumption among children: the 5-a-Day Power Plus program in St. Paul, Minnesota. Am J Public Health. 1998;88(4):603–9. Edmundson EW, Luton SC, McGraw SA, Kelder SH, Layman AK, Smyth MH, et al. CATCH: classroom process evaluation in a multicenter trial. Health Educ Q. 1994;Suppl(2):27–S50. Inchley J, Muldoon J, Currie C. Becoming a health promoting school: evaluating the process of effective implementation in Scotland. Health Promot Int. 2007;22(1):65–71. Reynolds KD, Franklin FA, Leviton LC, Maloy J, Harrington KF, Yaroch AL, et al. Methods, results, and lessons learned from process evaluation of the high 5 school-based nutrition intervention. Health Educ Behav. 2000;27(2):177–86. Ismail MR, Seabrook JA, Gilliland JA. Outcome evaluation of fruits and vegetables distribution interventions in schools: a systematic review and meta-analysis. Public Health Nutr. 2021;24(14):4693–705. Lepe S, Goodwin J, Mulligan KT, Balestracci K, Sebelia L, Greene G. Process Evaluation of a Policy, Systems, and Environmental Change Intervention in an Urban School District. J Nutr Educ Behav. 2019;51(3):307–17. Christian MS, Evans CE, Ransley JK, Greenwood DC, Thomas JD, Cade JE. Process evaluation of a cluster randomised controlled trial of a school-based fruit and vegetable intervention: Project Tomato. Public Health Nutr. 2012;15(3):459–65. Bere E, Veierød MB, Bjelland M, Klepp KI. Outcome and process evaluation of a Norwegian school-randomized fruit and vegetable intervention: Fruits and Vegetables Make the Marks (FVMM). Health Educ Res. 2006;21(2):258–67. Bonde AH, Stjernqvist NW, Sabinsky MS, Maindal HT. Process evaluation of implementation fidelity in a Danish health-promoting school intervention. BMC Public Health. 2018;18(1):1407. Additional Declarations No competing interests reported. Supplementary Files AdditionalFile1.DAIREinterventions.docx AdditionalFile2.NourishEvaluationQuestionnaire.docx AdditionalFile3.EngageTeacherEval.Questionnaire.docx AdditionalFile4NourishObservationTool.docx AdditionalFile5EngageObservationTool003.docx AdditionalFile6.FollowupQuestionnaires.docx AdditionalFile7.DAIRErecruitmentprocess.docx AdditionalFile8.Engagetopicsandlessons.docx AdditionalFile9.Engagespeakersvisitsactivities.docx AdditionalFile10.ETEQdataEngageresourcesutilised.docx AdditionalFile11.RisksofcontaminationinDAIRE.docx Cite Share Download PDF Status: Published Journal Publication published 06 Feb, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 25 Jun, 2024 Reviews received at journal 24 Jun, 2024 Reviews received at journal 18 Jun, 2024 Reviews received at journal 15 Jun, 2024 Reviewers agreed at journal 10 Jun, 2024 Reviewers agreed at journal 09 Jun, 2024 Reviewers agreed at journal 08 Jun, 2024 Reviews received at journal 02 Jun, 2024 Reviewers agreed at journal 27 May, 2024 Reviewers invited by journal 27 May, 2024 Editor assigned by journal 02 May, 2024 Editor invited by journal 03 Jan, 2024 Submission checks completed at journal 03 Jan, 2024 First submitted to journal 15 Dec, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3757991","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":264972380,"identity":"f16c2f18-a3b1-41d2-88e3-ec5e6ca4c353","order_by":0,"name":"Naomi Anderson","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Naomi","middleName":"","lastName":"Anderson","suffix":""},{"id":264972381,"identity":"07941099-21bd-48f3-9669-d2de417b29b5","order_by":1,"name":"Sarah F. Brennan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIiWNgGAWjYJACZgaGA1BmBQODAYSVQKyWMyRrYWwjQot8+9mHnwsY7uTzS/ce/Fw4zzpxOwPzww+MbWk4tRicSTeWnsHwzHLmnHPJ0jO3pSfubGAzlmBsy8GthSGNQZqH4bCBwY0cA2nebYcTNxxgMAO6sAK3w/qfMf8GabG/kWP8m3cOSAv7N7xaGG6ksUFskcgxk+ZtAGnhAdmCx2E3nrFZ8xg8M5C4kWNmzXMs3XhnM0+xRMI53N6X709jvs1TcceAf0aO8W2eGmvZ7eztGz98KEvG7TBoIMAAMxgRiEhUwEyC2lEwCkbBKBgpAAAaf03texA4XQAAAABJRU5ErkJggg==","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":true,"prefix":"","firstName":"Sarah","middleName":"F.","lastName":"Brennan","suffix":""},{"id":264972382,"identity":"a9407fae-0e12-4d57-8824-b5b87d7aaf87","order_by":2,"name":"Fiona Lavelle","email":"","orcid":"","institution":"King's College London","correspondingAuthor":false,"prefix":"","firstName":"Fiona","middleName":"","lastName":"Lavelle","suffix":""},{"id":264972383,"identity":"4774fc38-1d09-4ee6-8aab-ed2f0d61690d","order_by":3,"name":"Sarah E. Moore","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"E.","lastName":"Moore","suffix":""},{"id":264972384,"identity":"e7ddc3f1-2e3e-4511-a0b1-9762778f2847","order_by":4,"name":"Dilara Olgacher","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Dilara","middleName":"","lastName":"Olgacher","suffix":""},{"id":264972385,"identity":"b8293c5c-4ac8-49c4-87c2-f4edf838e557","order_by":5,"name":"Amy Junkin","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Amy","middleName":"","lastName":"Junkin","suffix":""},{"id":264972386,"identity":"a5480ef6-57a5-455f-89c1-745b00163049","order_by":6,"name":"Moira Dean","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Moira","middleName":"","lastName":"Dean","suffix":""},{"id":264972387,"identity":"1fe77fee-46ce-4d41-9d08-3d9be5a36c97","order_by":7,"name":"Michelle C. McKinley","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Michelle","middleName":"C.","lastName":"McKinley","suffix":""},{"id":264972388,"identity":"8cda47f3-6df1-4b9b-93fe-9f1aa0f91e61","order_by":8,"name":"Patrick McCole","email":"","orcid":"","institution":"Maynooth University","correspondingAuthor":false,"prefix":"","firstName":"Patrick","middleName":"","lastName":"McCole","suffix":""},{"id":264972389,"identity":"7220db51-c7ca-4164-9256-caea79e0628d","order_by":9,"name":"Ruth F. Hunter","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Ruth","middleName":"F.","lastName":"Hunter","suffix":""},{"id":264972390,"identity":"1cbbd9c3-cb12-4500-b9c8-1af8ee82e7d0","order_by":10,"name":"Laura Dunne","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Laura","middleName":"","lastName":"Dunne","suffix":""},{"id":264972391,"identity":"e6ae5c03-80a9-422a-821d-c0ff01d97413","order_by":11,"name":"Niamh E. O’Connell","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Niamh","middleName":"E.","lastName":"O’Connell","suffix":""},{"id":264972392,"identity":"1ee4167e-0c54-4ea3-8e99-fa93baf92479","order_by":12,"name":"Chris T. Elliott","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Chris","middleName":"T.","lastName":"Elliott","suffix":""},{"id":264972393,"identity":"6e7c397e-6367-4f2f-b45b-f32368551f66","order_by":13,"name":"Danielle McCarthy","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Danielle","middleName":"","lastName":"McCarthy","suffix":""},{"id":264972394,"identity":"109ee9dc-66e8-4219-9531-6dcb3f9d8843","order_by":14,"name":"Jayne V. Woodside","email":"","orcid":"","institution":"Queen’s University Belfast","correspondingAuthor":false,"prefix":"","firstName":"Jayne","middleName":"V.","lastName":"Woodside","suffix":""}],"badges":[],"createdAt":"2023-12-15 09:59:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3757991/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3757991/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-21628-4","type":"published","date":"2025-02-06T15:57:27+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":49240874,"identity":"b54aed17-f88f-46f5-8b43-7a90f36f376f","added_by":"auto","created_at":"2024-01-05 18:23:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":278339,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOutline of DAIRE intervention components\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3757991/v1/70e0cbf3b17b06b11bb189b6.png"},{"id":75930394,"identity":"e37a4339-34b9-4ace-bde5-80fe5a844210","added_by":"auto","created_at":"2025-02-10 16:11:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1986396,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3757991/v1/5d30bc82-1fb1-4973-9618-332af1c20213.pdf"},{"id":49243412,"identity":"1d7862d6-3cbe-4f18-ba3a-9d07de7e5c04","added_by":"auto","created_at":"2024-01-05 18:39:09","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":106986,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile1.DAIREinterventions.docx","url":"https://assets-eu.researchsquare.com/files/rs-3757991/v1/c30fb489ec07237043ae2a9f.docx"},{"id":49240876,"identity":"048b4949-8947-433f-814c-3edcbc75ca98","added_by":"auto","created_at":"2024-01-05 18:23:09","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":197021,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile2.NourishEvaluationQuestionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-3757991/v1/2dffaeadeacef57d31830944.docx"},{"id":49242631,"identity":"9c0ca62a-3c52-4adb-9375-fb4c3dcb0e9c","added_by":"auto","created_at":"2024-01-05 18:31:09","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":231829,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile3.EngageTeacherEval.Questionnaire.docx","url":"https://assets-eu.researchsquare.com/files/rs-3757991/v1/993ca021b83c933bee08799f.docx"},{"id":49240875,"identity":"cccda661-7e3a-458c-8d98-af4aad813b85","added_by":"auto","created_at":"2024-01-05 18:23:09","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":132851,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile4NourishObservationTool.docx","url":"https://assets-eu.researchsquare.com/files/rs-3757991/v1/f7bf2ed26ab27933f901f128.docx"},{"id":49243679,"identity":"fc1c7b50-ac41-47f6-8375-3669955935e7","added_by":"auto","created_at":"2024-01-05 18:47:09","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":133879,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile5EngageObservationTool003.docx","url":"https://assets-eu.researchsquare.com/files/rs-3757991/v1/66448f520aed4e5809c61484.docx"},{"id":49242628,"identity":"b0c1ae32-4ce5-47bc-b89a-9fe94a0ce791","added_by":"auto","created_at":"2024-01-05 18:31:09","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":46771,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile6.FollowupQuestionnaires.docx","url":"https://assets-eu.researchsquare.com/files/rs-3757991/v1/1c836b34fdf555860ffb3722.docx"},{"id":49240881,"identity":"936b7356-f263-4f0a-b4cf-44962cd227b3","added_by":"auto","created_at":"2024-01-05 18:23:09","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":80294,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile7.DAIRErecruitmentprocess.docx","url":"https://assets-eu.researchsquare.com/files/rs-3757991/v1/32b3a1537304ccfe24ca9947.docx"},{"id":49240878,"identity":"56009b80-aa1f-454b-80e3-297c2a22ead3","added_by":"auto","created_at":"2024-01-05 18:23:09","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":16846,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile8.Engagetopicsandlessons.docx","url":"https://assets-eu.researchsquare.com/files/rs-3757991/v1/eeef8a92a0b0ca4e3cb3e7cf.docx"},{"id":49240885,"identity":"2e463b68-c8c6-42a7-941e-b6830caa376b","added_by":"auto","created_at":"2024-01-05 18:23:09","extension":"docx","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":16004,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile9.Engagespeakersvisitsactivities.docx","url":"https://assets-eu.researchsquare.com/files/rs-3757991/v1/f9e09bd1bab586e11629a446.docx"},{"id":49243413,"identity":"7afe32c5-d86e-47e0-85ff-18ea2152d327","added_by":"auto","created_at":"2024-01-05 18:39:09","extension":"docx","order_by":10,"title":"","display":"","copyAsset":false,"role":"supplement","size":21183,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile10.ETEQdataEngageresourcesutilised.docx","url":"https://assets-eu.researchsquare.com/files/rs-3757991/v1/57c30934564d843c33c15402.docx"},{"id":49240884,"identity":"9719ddb0-a557-42eb-b4d8-0dd53ea5099a","added_by":"auto","created_at":"2024-01-05 18:23:09","extension":"docx","order_by":11,"title":"","display":"","copyAsset":false,"role":"supplement","size":84426,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFile11.RisksofcontaminationinDAIRE.docx","url":"https://assets-eu.researchsquare.com/files/rs-3757991/v1/f1cb59809c1cd2a828b37951.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Process evaluation of Project Daire: a food environment intervention that impacted food knowledge, wellbeing and dietary habits of primary school children","fulltext":[{"header":"Background","content":"\u003cp\u003eThe link between childhood diet and disease prevention in adulthood is well established and research suggests that eating patterns track from childhood to adulthood (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Consequently, establishing healthy dietary patterns in childhood is critical to influencing future disease risk and adult health status (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Schools have been recognized as ideal environments for public health interventions (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) due to the proportion of time children spend in school and the significant number of meals consumed in this setting. As such, calls for action to policy makers to improve the dietary quality of food provided in the school setting has intensified (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and a whole-school approach advocated (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDAIRE was a school-based randomised-controlled, factorial design four-arm trial conducted in Northern Irish (NI) primary school settings. DAIRE tested elements of the whole school approach through two interventions \u0026ndash; Nourish and Engage. Nourish was a food environment intervention which focused on food provision, resources to improve school food presentation and the school food environment, fun-based food-related experiences and exposure to locally produced foods. Engage was an age-appropriate cross-curricular food education intervention, which involved educational food topics, interactive lessons and engaging food experiences in the community. Project Daire worked in partnership with primary schools and a range of stakeholders, including teachers, principals, school caterers and local food producers, to develop and deliver the interventions. The study demonstrated that improvements in childhood emotional and behavioural wellbeing, dietary intake, knowledge about food, cooking skills and willingness to try new foods were associated with the \u0026lsquo;Nourish\u0026rsquo; whole-school food environment intervention (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSchools-based interventions are complex and therefore conducting a process evaluation (PE) is important to understand how and under what conditions programmes might work. Due to the complex nature of DAIRE and to fully understand its outcomes, we have conducted a mixed-methods process evaluation using data collected throughout the DAIRE study and following the MRC framework to evaluate DAIRE implementation, mechanisms of impact (MOI) and context (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe objectives were:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo evaluate implementation \u0026ndash;through evaluating fidelity, acceptability, dose, reach, recruitment, retention and contamination of both the Nourish and Engage interventions.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo evaluate the MOI of both the Nourish and Engage interventions.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo evaluate context of the Nourish and Engage interventions and determine which contextual factors hindered and supported effective implementation of DAIRE and influence intervention outcomes.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo provide scientific rationale for modifications to the Nourish and Engage interventions which will facilitate successful and effective future DAIRE rollout.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003e\u003cstrong\u003eDAIRE study design\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe DAIRE study protocol and main outcomes are published elsewhere (7). A total of 15 schools were randomized to one of the four intervention arms: i) \u0026lsquo;Nourish\u0026rsquo; (n=4), ii) \u0026lsquo;Engage\u0026rsquo; (n=3), iii) \u0026lsquo;Nourish and Engage\u0026rsquo; (n=4) and iv) \u0026lsquo;Control\u0026rsquo; (Delayed) (n=4). The specific components of the interventions are outlined in Additional File 1. Ethical approval for DAIRE was obtained from the School of Social Sciences, Education and Social Work Ethics Committee, Queen\u0026rsquo;s University Belfast (Reference number 038_1819).\u003c/p\u003e\n\u003cp\u003eThe significant improvements in outcomes measured in DAIRE were associated with the Nourish intervention, with a statistically significant reduction in mean Total Difficulties Score (TDS), an emotional and behavioural screening tool and one of the primary outcomes, which indicated an improvement in behaviour (11). The Nourish intervention also produced some changes in school-based dietary behaviour, which were most apparent in the 10\u0026ndash;11 year old pupils, and improvements in understanding of food labels and knowledge of vegetables in season, whilst an increased willingness to try new foods and improved perceived cooking competence was also observed. A significant difference in Health-related Quality of Life (HRQOL) (KIDSCREEN-10) (12) of males randomised to Nourish was observed in subgroup analysis. No statistically significant difference in primary outcomes was observed in those randomised to the Engage intervention (7). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDAIRE process evaluation design, sample population and data collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe DAIRE process evaluation design, key functions and interrelationships, adapted from Moore et al. is outlined in \u003cstrong\u003eFigure 1\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1: Outline of DAIRE intervention components\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eSample population\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn total 15 schools and 983 pupils (n=495 Key Stage 1 (KS1) pupils (Year 3) and n=488 Key Stage 2 (KS) pupils (Year 7)) were recruited for the DAIRE intervention. The total number of pupils (n=494 males and n=489 females) allocated to the DAIRE interventions were as follows i) Nourish (n=189), ii) Engage (n=244), iii) Nourish and Engage (n=308) and iv) Control (Delayed) (n=242). Additionally, three Irish language schools expressed interest in participating but, as it was not feasible in terms of time or funding to translate all intervention resources in the event that these schools were allocated to one of the Engage intervention arms, these schools were not randomized but received the Nourish intervention instead. Outcome measures were translated to the Irish language and then back translated for the 3 Irish language schools to facilitate ecological validity as far as possible and enable children to complete in the appropriate language. \u0026nbsp;As such, data collected from these schools were presented separately in the main paper (7).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eProcess Evaluation Data Collection\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative and qualitative process evaluation data were collected throughout DAIRE in both a formal and informal manner, as shown in \u003cstrong\u003eTable 1\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u0026nbsp;\u003c/strong\u003eDAIRE process evaluation data collected\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"558\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.258527827648114%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"61.57989228007181%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.161579892280074%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eData Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.258527827648114%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"61.57989228007181%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.080789946140037%\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuantitative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.080789946140037%\"\u003e\n \u003cp\u003e\u003cstrong\u003eQualitative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.258527827648114%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eFormal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"61.57989228007181%\"\u003e\n \u003cp\u003eNEQ (completed by teachers)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.080789946140037%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"15.080789946140037%\"\u003e\n ✔\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eETEQ (completed by teachers)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eNOT (completed by study researchers)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eEOT (completed by study researchers)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.258527827648114%\" rowspan=\"15\"\u003e\n \u003cp\u003e\u003cstrong\u003eInformal (study records)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"61.57989228007181%\"\u003e\n \u003cp\u003eNourish implementation summary document (study researcher records)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.080789946140037%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"15.080789946140037%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eNourish field notes records (study researcher records)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eNourish planned Tasting Days document (study researcher records)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eEmails regarding healthy snack delivery (communication received from industry partners)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eMobile Petting Farm visit records (communication received from company and study researcher records)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eEngage schools records (study researcher records)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eCompleted lessons records (teacher and study researcher records)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eDAIRE feedback and quotes document (study researcher records of verbal feedback received from teachers during data collection)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eOverview of Engage delivery on DAIRE researcher document (teacher and study researcher records)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eDAIRE guest speakers document (study researcher records)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eRecords on class perceptions of the completed PE lesson (study researcher records)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eEmail communication on school recruitment (communication received from school management)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eClass lists and opt-outs information (communication received from school management)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eRecords of numbers of baseline/end-point pupils (study researcher records)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"67.12328767123287%\"\u003e\n \u003cp\u003eSchool food environment dataset (study researcher records)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003ctd width=\"16.438356164383563%\"\u003e\n ✔\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: NEQ, Nourish Evaluation Questionnaire; ETEQ, Engage Teacher Evaluation Questionnaire; NOT, Nourish Observation Tool; EOT, Engage Observation Tool\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFormal Data Collection\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProcess-Evaluation specific questionnaires were developed by the research team based on study protocol and informed by the MRC framework (13) and formed the majority of the structured formal data collection for the DAIRE PE.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSpecifically, two teacher evaluation questionnaires were developed:\u0026nbsp;\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eThe Nourish Evaluation Questionnaire (NEQ) (Additional File 2).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eThe Engage Teacher Evaluation Questionnaire (ETEQ) (Additional File 3).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe questionnaires comprised of 18 questions and were designed to be administered to intervention schools only, with the ETEQ administered to primary school teachers and the NEQ administered to the most relevant school personnel within each school i.e., teaching staff, principal/vice principal, catering/canteen staff. Both the NEQ and ETEQ were administered at the end of the intervention period.\u003c/p\u003e\n\u003cp\u003eIn addition, two observational tools were also developed, which were informed by the MRC framework (13):\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eNourish Observation tool (NOT) (Additional File 4).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEngage Observation tool (EOT) (Additional File 5).\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe 15-item NOT and 16-item EOT were intended for use by DAIRE researchers to observe intervention lessons and activities in the field following school permission.\u003c/p\u003e\n\u003cp\u003eThe questionnaires and observation tools were based on the three MRC framework elements and were designed to collect quantitative and qualitative information on: intervention delivery, appropriateness and usefulness of intervention elements, any adaptations that were made by teachers to intervention elements, whether substitute teachers were in place during intervention delivery, level of pupil engagement with the interventions, any barriers experienced during delivery, general opinions on the interventions and the presence of similar health initiatives in schools during the intervention period (13).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eInformal Data Collection\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformal data, i.e. data collected naturally as part of the study (data not collected by the developed structured questionnaires), were also collected by DAIRE researchers at schools randomised to the intervention groups throughout the intervention period (see \u003cstrong\u003eTable 1\u003c/strong\u003e). Informal data included content and dates of relevant emails and other communications sent by school personnel, guest speakers and food industry partners regarding the Nourish and Engage interventions, and conversations and comments made during the data collection period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-Up Interviews\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe DAIRE team planned to conduct follow-up interviews with school staff about their views and experiences of DAIRE but were unable to do so due to COVID-19-related school closures. Instead, one year after completion of the study, follow-up questionnaires (Additional File 6) were emailed to the schools which were designed to be completed by school representatives (e.g. principals, teachers and/or caterers) and collected quantitative and qualitative data on the impact of DAIRE on individual school food policies, healthy snack provision, use of DAIRE components after the intervention period, and suggestions for future implementation of DAIRE. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eData Analyses\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative data were entered into SPSS and cleaned prior to analysis. Qualitative data were compiled, analysed and coded according to the specific element(s) of the DAIRE process evaluation framework they were relevant to. \u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003epresents the data which were used to investigate each section of the DAIRE process evaluation whilst \u003cstrong\u003eTable 3\u003c/strong\u003e outlines how results are presented and statistical analyses used.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQuantitative questionnaire data (NEQ and ETEQ) were analysed using SPSS statistical analysis software V 27.0. Descriptive statistics (frequencies, means, \u0026plusmn; standard deviation and percent values) were calculated to determine the implementation \u0026ndash; specifically fidelity, dose, reach, recruitment, retention and acceptability, MOI and context aspects of the framework (\u003cstrong\u003eTable 3)\u003c/strong\u003e.\u0026nbsp;Thematic analysis of qualitative data was conducted following the Braun and Clarke (14) six step framework for the implementation \u0026ndash; specifically fidelity, dose and acceptability, MOI, and context aspects of the framework (\u003cstrong\u003esee Table 2 for data used\u003c/strong\u003e). Codes were identified inductively by a study researcher based on the frequency of key words, phrases, opinions and concepts within the data and then combined into themes ensuring that there was sufficient supporting data for each theme. All themes and codes were critically discussed and checked within the research team until a consensus was reached.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 2:\u003c/strong\u003e The DAIRE process evaluation framework and the data used to investigate each element\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"983\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.311291963377418%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eDAIRE process evaluation element\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"81.68870803662259%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eData used to investigate\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNourish \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Engage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.458799593082401%\" rowspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eImplementation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.852492370295016%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eRecruitment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.45371312309258%\"\u003e\n \u003cp\u003eEmail communication on school recruitment\u003c/p\u003e\n \u003cp\u003eClass lists and opt-out information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.23499491353001%\"\u003e\n \u003cp\u003eEmail communication on school recruitment\u003c/p\u003e\n \u003cp\u003eClass lists and opt-out information\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eRetention\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.831401475237094%\"\u003e\n \u003cp\u003eRecords of numbers of baseline/end-point pupils\u003c/p\u003e\n \u003cp\u003eClass lists and opt-out information\u003c/p\u003e\n \u003cp\u003eComplete responses data for HRQOL and SDQ scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.78398314014753%\"\u003e\n \u003cp\u003eRecords of numbers of baseline/end-point pupils\u003c/p\u003e\n \u003cp\u003eClass lists and opt-out information\u003c/p\u003e\n \u003cp\u003eComplete responses data for HRQOL and SDQ scores\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eReach\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.831401475237094%\"\u003e\n \u003cp\u003eEmail communication on school recruitment\u003c/p\u003e\n \u003cp\u003eNOT \u0026ndash; Q7, Q8, Q9\u003c/p\u003e\n \u003cp\u003eClass lists and opt-out information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.78398314014753%\"\u003e\n \u003cp\u003eEmail communication on school recruitment\u003c/p\u003e\n \u003cp\u003eEOT \u0026ndash; Q6, Q7, Q8\u003c/p\u003e\n \u003cp\u003eClass lists and opt-out information\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eFidelity\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eAnd\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDose\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.831401475237094%\"\u003e\n \u003cp\u003eNOT \u0026ndash; Q1, Q2, Q4, Q5, Q6, Q8, Q10, Q11, Q14, Q15\u003c/p\u003e\n \u003cp\u003eNEQ \u0026ndash; Q1, Q2, Q3, Q4, Q18\u003c/p\u003e\n \u003cp\u003eNourish implementation summary document\u003c/p\u003e\n \u003cp\u003eNourish school field notes records\u003c/p\u003e\n \u003cp\u003eNourish planned Tasting Days document\u003c/p\u003e\n \u003cp\u003eEmails regarding healthy snack delivery\u003c/p\u003e\n \u003cp\u003eComplete responses data for HRQOL and SDQ scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.78398314014753%\"\u003e\n \u003cp\u003eETEQ \u0026ndash; Q1, Q2, Q3, Q6, Q8, Q10\u003c/p\u003e\n \u003cp\u003eEOT \u0026ndash;Q5, Q6, Q7, Q8, Q9. Q10, Q15, Q16\u003c/p\u003e\n \u003cp\u003eMobile Petting Farm visits records\u003c/p\u003e\n \u003cp\u003eEngage schools records\u003c/p\u003e\n \u003cp\u003eCompleted lessons records\u003c/p\u003e\n \u003cp\u003eComplete responses data for HRQOL and SDQ scores\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcceptability\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.831401475237094%\"\u003e\n \u003cp\u003eNOT \u0026ndash; Q2, Q4, Q5, Q6, Q10, Q11, Q14, Q15\u003c/p\u003e\n \u003cp\u003eNEQ \u0026ndash; Q5, Q6, Q7, Q9, Q10, Q14, Q15, Q17\u003c/p\u003e\n \u003cp\u003eDAIRE feedback and quotes document\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.78398314014753%\"\u003e\n \u003cp\u003eETEQ \u0026ndash; Q4, Q5, Q7, Q9, Q11, Q15, Q16, Q18\u003c/p\u003e\n \u003cp\u003eOverview of Engage delivery on DAIRE document\u003c/p\u003e\n \u003cp\u003eDAIRE feedback and quotes document\u003c/p\u003e\n \u003cp\u003eDAIRE guest speakers document\u003c/p\u003e\n \u003cp\u003eProcess Evaluation class copy of perceptions dataset\u003c/p\u003e\n \u003cp\u003eEOT \u0026ndash;Q5, Q6, Q7, Q8, Q9. Q10, Q15, Q16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eContamination\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"39.831401475237094%\"\u003e\n \u003cp\u003eBrennan et al. (7) main DAIRE paper:\u0026nbsp;intervention study design, recruitment, randomisation and allocation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.78398314014753%\"\u003e\n \u003cp\u003eBrennan et al. (7) main DAIRE paper: intervention study design, recruitment, randomisation and allocation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.311291963377418%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMechanisms of impact\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.45371312309258%\"\u003e\n \u003cp\u003eNEQ \u0026ndash; Q3, Q5, Q6, Q7, Q9, Q10, Q14\u003c/p\u003e\n \u003cp\u003eNOT \u0026ndash; Q6, Q10, Q14\u003c/p\u003e\n \u003cp\u003eJunkin (15) Msci paper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.23499491353001%\"\u003e\n \u003cp\u003eETEQ \u0026ndash; Q4, Q5, Q7, Q9, Q11, Q15\u003c/p\u003e\n \u003cp\u003eEOT \u0026ndash; Q5,Q9,Q15, Q16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.311291963377418%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eContext\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.45371312309258%\"\u003e\n \u003cp\u003eNEQ \u0026ndash; Q3, Q11, Q12, Q13, Q16\u003c/p\u003e\n \u003cp\u003eSchool food environment dataset\u003c/p\u003e\n \u003cp\u003eNourish implementation summary document\u003c/p\u003e\n \u003cp\u003eComplete responses data for HRQOL and SDQ scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.23499491353001%\"\u003e\n \u003cp\u003eETEQ \u0026ndash; Q3, Q6, Q10, Q12, Q13, Q14\u003c/p\u003e\n \u003cp\u003eEngage schools records\u003c/p\u003e\n \u003cp\u003eSchool food environment dataset\u003c/p\u003e\n \u003cp\u003eCompleted lessons records\u003c/p\u003e\n \u003cp\u003eComplete responses data for HRQOL and SDQ scores\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: HRQOL, Health-related Quality of Life; SDQ, Strengths and Difficulties; NEQ, Nourish Evaluation Questionnaire; ETEQ, Engage Teacher Evaluation Questionnaire; NOT, Nourish Observation Tool; EOT, Engage Observation Tool\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e How each DAIRE process evaluation element was investigated\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"612\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.77777777777778%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDAIRE process evaluation element and MRC definition\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(16)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.22222222222223%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow each element was investigated\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.77777777777778%\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecruitment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.22222222222223%\"\u003e\n \u003cp\u003eExpressed as the total number of pupils in each intervention arm and DAIRE as a whole.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.77777777777778%\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.22222222222223%\"\u003e\n \u003cp\u003eExpressed as the mean % of opt-out pupils, as well as the % completion rate of complete (both baseline and endpoint) data responses for the KIDSCREEN-10 questionnaire and Strength and Difficulties (SDQ) questionnaire.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.77777777777778%\"\u003e\n \u003cp\u003e\u003cstrong\u003eReach\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;the extent to which a target audience comes into contact with the intervention\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.22222222222223%\"\u003e\n \u003cp\u003eUsing recruitment and retention data to determine the extent to which primary school children aged 6-7 and 10-11 years in the North West region of NI came into contact with DAIRE.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.77777777777778%\"\u003e\n \u003cp\u003e\u003cstrong\u003eFidelity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;the consistency of what was implemented with the planned intervention\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.22222222222223%\"\u003e\n \u003cp\u003eNourish fidelity was determined the % of Nourish elements delivered and made available to schools, and the % of Nourish elements delivered in each individual school\u003c/p\u003e\n \u003cp\u003eEngage fidelity was determined as the % of Engage elements made available to schools, the mean % of topic 1, topic 2 and topic 3 delivered in Engage schools, and the mean % of guest speakers, visits and activities implemented in schools\u003c/p\u003e\n \u003cp\u003eThematic analysis of informal data sources outlined in \u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.77777777777778%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDose\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;the quantity of intervention delivered\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.22222222222223%\"\u003e\n \u003cp\u003eNourish dose was expressed as the mean % of Nourish elements delivered in schools\u003c/p\u003e\n \u003cp\u003eEngage dose was expressed in two ways: A) The % of schools which achieved Core Engage delivery\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eB) The mean % of engage topics, guest speakers, food industry visits and activities (out of 26 elements) delivered in schools\u003c/p\u003e\n \u003cp\u003eThematic analysis of informal data sources outlined in \u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.77777777777778%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAcceptability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.22222222222223%\"\u003e\n \u003cp\u003eParticipant responses to Likert-scale questions in the NEQ and ETEQ were coded on a 5-point scale ranging from 1 \u0026lsquo;Strongly Agree\u0026rsquo; to 5 \u0026lsquo;Strongly Disagree\u0026rsquo;. Mean score, standard deviation, frequencies and %\u0026rsquo;s were calculated and expressed, with a lower score indicating higher acceptability\u003c/p\u003e\n \u003cp\u003eThematic analysis of informal data sources outlined in \u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.77777777777778%\"\u003e\n \u003cp\u003e\u003cstrong\u003eContamination\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;The likelihood of control group participants being exposed to the active intervention\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.22222222222223%\"\u003e\n \u003cp\u003eExamining the likelihood of DAIRE control group participants being exposed to the Nourish and Engage interventions through examining the DAIRE intervention study design, recruitment, randomisation and allocation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.77777777777778%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMechanism of Impact\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;How did the delivered intervention produce change?\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.22222222222223%\"\u003e\n \u003cp\u003eFrequencies and %\u0026rsquo;s were calculated with regards relevant NEQ and ETEQ questions on pupil reaction to the interventions and which elements were most useful and appropriate (see \u003cstrong\u003eTable 2\u003c/strong\u003e).\u003c/p\u003e\n \u003cp\u003eThematic analysis of informal data sources outlined in \u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.77777777777778%\"\u003e\n \u003cp\u003e\u003cstrong\u003eContext\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026lsquo;Factors external to the intervention which may influence implementation, or whether MOI act as intended\u0026rsquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"72.22222222222223%\"\u003e\n \u003cp\u003eFrequencies and %\u0026rsquo;s were calculated with regards both the schools and teachers at classroom level who reported barriers, the presence of similar health initiatives and if substitute teachers were in place during intervention delivery\u003c/p\u003e\n \u003cp\u003eThematic analysis of informal data sources outlined in \u003cstrong\u003eTable 2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 51.6% (n=16) of the NEQ and 42.3% (n=11) of the ETEQ were returned by teachers and 9.7% (n=3) of the NOT and 9.1% (n=1) of the EOT were completed by the research team.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation \u0026ndash; Recruitment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe DAIRE intervention recruitment process, which was completed over a 6-week period (Jan-Feb 2019) and resulted in 15 randomised schools, is available in Additional File 7.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRetention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 100% retention rate was observed at both school and pupil level, with no schools (n=15) dropping out, or pupils withdrawing consent once the DAIRE intervention began. Only five schools provided information regarding individual numbers of pupils who opted-out (data on n=128/983 pupils); indicative of 13% of pupils based on this subset. Retention was also determined in terms of the number of paired baseline and end-point responses for primary outcomes within the 15 randomised DAIRE schools (n=983 pupils).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe\u0026nbsp;rate of completion for the pupil- focused Strength and Difficulties questionnaire, completed by teachers, was much lower (54.2%; n=533) than the pupil-completed questionnaire for the primary outcome, KIDSCREEN-10 questionnaire, with 79.7% (n=783) completing both at baseline and end-point\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e(11 and 12).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReach\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt was not feasible to assess the exact % of primary school children aged 6-7 and 10-11 years in the NW region of NI that DAIRE reached, as there are no publicly available data on the number of pupils by age group in the region. However, in total, DAIRE reached 983 primary school children (n=495 aged 6-7 and n=488 aged 10-11 years) and, considering a total of 142 mainstream primary schools in the NW region of NI were contacted, with an approach aiming to include schools in both urban and rural locations, both faith and non-faith based schools and those where English was not used as first language (Irish language schools), DAIRE recruited 10.6% (n=15 randomised) of possible mainstream primary schools within this region.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFidelity and Dose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNourish Intervention\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA delayed DAIRE intervention start date, in March rather than February 2019, resulted in late delivery of some Nourish intervention elements (May 2019) and the closure of schools for the summer recess in June 2019, is likely to have affected Nourish implementation and, as a result, observed primary and secondary outcomes.\u003c/p\u003e\n\u003cp\u003eIn total, 100% (n=8) of Nourish schools received intervention elements and resources to enable complete intervention delivery. An additional option to hold a school food event sponsored by food industry partners was offered to only n=3 Nourish randomised schools due to practicalities and n=2 availed of this opportunity. \u003cstrong\u003eTable 4\u003c/strong\u003e highlights that, on average, Nourish schools (n=8) implemented 61.4% of the Nourish intervention, (range of 28.6% school Q to 85.7% school G).\u003c/p\u003e\n\u003cp\u003eThe most delivered Nourish element was healthy snack provision, which 100% (n=8) of Nourish schools availed of. A total of 75% (n=6) and 87.5% (n=7) of schools utilised equipment to enhance the school environment and presentation of food respectively, and 50% (n=4) of schools utilised cookery equipment and recipes. A high percentage of 87.5% (n=7) of schools attended Tasting Days. One school utilised the sensory education tool (n=1, 12.5%) and one (12.5%) availed of the opportunity to optimize their school food policy by booking an individual session with a member of the DAIRE research team. As this was low, all schools (100%) received a general document with advice relating to school food policies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u0026nbsp;Table 4:\u003c/strong\u003e Summary of Nourish intervention elements implemented\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"693\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.533910533910534%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchool Code\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"78.35497835497836%\" colspan=\"8\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Nourish elements\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.11111111111111%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eNourish elements delivered at individual school level\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003en (\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"11.439114391143912%\"\u003e\n \u003cp\u003e\u003cem\u003eHealthy snack provision\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.236162361623617%\"\u003e\n \u003cp\u003e\u003cem\u003eEnhancement of dining area\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.760147601476016%\"\u003e\n \u003cp\u003e\u003cem\u003eEnhanced food presentation\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.915129151291513%\"\u003e\n \u003cp\u003e\u003cem\u003eCookery equipment and recipes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.177121771217712%\"\u003e\n \u003cp\u003e\u003cem\u003eSensory education\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.439114391143912%\"\u003e\n \u003cp\u003e\u003cem\u003eOptimise school food policies\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.51660516605166%\"\u003e\n \u003cp\u003e\u003cem\u003eTasting day\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.51660516605166%\"\u003e\n \u003cp\u003e\u003cem\u003eSchool food event*\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.54913294797688%\"\u003e\n \u003cp\u003e\u003cstrong\u003eE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"12.716763005780347%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"11.560693641618498%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"10.115606936416185%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"9.53757225433526%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.127167630057803%\"\u003e\n \u003cp\u003e5(71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.54913294797688%\"\u003e\n \u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"12.716763005780347%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"11.560693641618498%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"10.115606936416185%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"9.53757225433526%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.127167630057803%\"\u003e\n \u003cp\u003e5(71.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.54913294797688%\"\u003e\n \u003cp\u003e\u003cstrong\u003eG\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"12.716763005780347%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"11.560693641618498%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.115606936416185%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"9.53757225433526%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.127167630057803%\"\u003e\n \u003cp\u003e6(85.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.54913294797688%\"\u003e\n \u003cp\u003e\u003cstrong\u003eJ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"12.716763005780347%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"11.560693641618498%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.115606936416185%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"9.53757225433526%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"11.127167630057803%\"\u003e\n \u003cp\u003e5(62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.54913294797688%\"\u003e\n \u003cp\u003e\u003cstrong\u003eL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"12.716763005780347%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.560693641618498%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"10.115606936416185%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.53757225433526%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"11.127167630057803%\"\u003e\n \u003cp\u003e4(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.54913294797688%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"12.716763005780347%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"11.560693641618498%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"10.115606936416185%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.53757225433526%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.127167630057803%\"\u003e\n \u003cp\u003e4(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.54913294797688%\"\u003e\n \u003cp\u003e\u003cstrong\u003eQ\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"12.716763005780347%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"11.560693641618498%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.115606936416185%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.53757225433526%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.127167630057803%\"\u003e\n \u003cp\u003e2(28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.54913294797688%\"\u003e\n \u003cp\u003e\u003cstrong\u003eR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"12.716763005780347%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.560693641618498%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"10.115606936416185%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.53757225433526%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e\n \u003cp\u003eX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.127167630057803%\"\u003e\n \u003cp\u003e3(42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.54913294797688%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNourish schools who delivered element (n=8)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e\n \u003cp\u003e8(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.716763005780347%\"\u003e\n \u003cp\u003e6(75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.560693641618498%\"\u003e\n \u003cp\u003e7(87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.115606936416185%\"\u003e\n \u003cp\u003e4(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.53757225433526%\"\u003e\n \u003cp\u003e1(12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.959537572254336%\"\u003e\n \u003cp\u003e1(12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e\n \u003cp\u003e7(87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.236994219653178%\"\u003e\n \u003cp\u003e2(66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.127167630057803%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"10\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Dose of Nourish elements delivered in schools (%):\u0026nbsp;\u003c/strong\u003e61.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"10\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD) number of Nourish elements delivered in schools:\u0026nbsp;\u003c/strong\u003e4.3 (1.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"10\"\u003e\n \u003cp\u003e*\u003cem\u003eOnly 2 schools offered this option. Note: N/A for school food event as schools not offered option to partake\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eEngage Intervention\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWith regards to Engage,\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e100% (n=7) of Engage schools received intervention materials to enable complete intervention delivery. Following early teacher feedback on the large volume of Engage content, DAIRE study researchers agreed with the Engage partner schools that a core minimum Engage delivery of five lessons with associated activities and one talk from a guest speaker should be completed for the intervention. Notably, 100% (n=7) of Engage schools implemented this minimum. However, as shown in \u003cstrong\u003eTable 5\u003c/strong\u003e, on average, Engage schools (n=7) implemented 50% of the original full intervention material, as outlined in Additional Files 8, 9 and 10. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5:\u003c/strong\u003e Summary of Engage elements implemented in schools\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"595\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.885906040268456%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEngage schools (n=7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.604026845637584%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCompleted 5 lessons with associated activities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.604026845637584%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCompleted 1 talk from a guest speaker\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean core minimum Engage delivered \u0026nbsp; \u003cem\u003en\u003c/em\u003e (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.61744966442953%\"\u003e\n \u003cp\u003e\u003cstrong\u003eEngage elements delivered per school\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=26 in total)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003en\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.59731543624161%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean dose of Engage elements delivered in schools (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD) number of Engage elements delivered in schools (n=26)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.885906040268456%\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.604026845637584%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"15.604026845637584%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"14.93288590604027%\" rowspan=\"7\"\u003e\n \u003cp\u003e7(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.61744966442953%\"\u003e\n \u003cp\u003e13(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.59731543624161%\" rowspan=\"7\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.758389261744966%\" rowspan=\"7\"\u003e\n \u003cp\u003e13 (1.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.905325443786982%\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.514792899408285%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"27.514792899408285%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"31.06508875739645%\"\u003e\n \u003cp\u003e12 (46.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.905325443786982%\"\u003e\n \u003cp\u003eO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.514792899408285%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"27.514792899408285%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"31.06508875739645%\"\u003e\n \u003cp\u003e14(53.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.905325443786982%\"\u003e\n \u003cp\u003eG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.514792899408285%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"27.514792899408285%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"31.06508875739645%\"\u003e\n \u003cp\u003e11(42.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.905325443786982%\"\u003e\n \u003cp\u003eL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.514792899408285%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"27.514792899408285%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"31.06508875739645%\"\u003e\n \u003cp\u003e15(57.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.905325443786982%\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.514792899408285%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"27.514792899408285%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"31.06508875739645%\"\u003e\n \u003cp\u003e15(57.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.905325443786982%\"\u003e\n \u003cp\u003eR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.514792899408285%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"27.514792899408285%\"\u003e✔\u003c/td\u003e\n \u003ctd width=\"31.06508875739645%\"\u003e\n \u003cp\u003e11(42.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcceptability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResults of Likert-scale questions (\u003cstrong\u003eTable 6\u003c/strong\u003e) revealed high acceptability of the Nourish and Engage interventions by teachers within a NI primary school setting.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 6:\u003c/strong\u003e Teacher Acceptability of the Nourish and Engage intervention as reported within the NEQ and ETEQ\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"755\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.294429708222812%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"92.70557029177719%\" colspan=\"10\"\u003e\n \u003cp\u003e\u003cstrong\u003ePart A) Nourish\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.819628647214856%\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.753315649867375%\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey Stage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.814323607427056%\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly Agree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.814323607427056%\"\u003e\n \u003cp\u003e\u003cstrong\u003eAgree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.018567639257295%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeither Agree nor Disagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.753315649867375%\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.079575596816976%\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrongly Disagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.946949602122016%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Score (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.819628647214856%\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eQ5\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Nourish resources, food items and activities useful and appropriate (n=16)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.753315649867375%\" rowspan=\"5\"\u003e\n \u003cp\u003eN/A\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.814323607427056%\"\u003e\n \u003cp\u003e14 (87.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.814323607427056%\"\u003e\n \u003cp\u003e2 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.018567639257295%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.753315649867375%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.079575596816976%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.946949602122016%\"\u003e\n \u003cp\u003e1.1(0.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.06395348837209%\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eQ6\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Delivery of Nourish elements (snacks, canteen decorations) organised and easy to manage (n=16)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.755813953488373%\"\u003e\n \u003cp\u003e9(56.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.755813953488373%\"\u003e\n \u003cp\u003e6(37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.883720930232558%\"\u003e\n \u003cp\u003e1(6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.593023255813954%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.046511627906977%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.901162790697674%\"\u003e\n \u003cp\u003e1.5(0.51)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.06395348837209%\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eQ7\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Organisation of Tasting Days adequate (n=12)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.755813953488373%\"\u003e\n \u003cp\u003e9 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.755813953488373%\"\u003e\n \u003cp\u003e2(16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.883720930232558%\"\u003e\n \u003cp\u003e1(8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.593023255813954%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.046511627906977%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.901162790697674%\"\u003e\n \u003cp\u003e1.3(0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.06395348837209%\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eQ9\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Pupil reaction to the Nourish intervention elements (e.g. snacks. Canteen decorations, food presentation, Tasting Days) was generally positive (n=16)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.755813953488373%\"\u003e\n \u003cp\u003e15 (93.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.755813953488373%\"\u003e\n \u003cp\u003e1 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.883720930232558%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.593023255813954%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.046511627906977%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.901162790697674%\"\u003e\n \u003cp\u003e1(0.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.06395348837209%\" colspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eQ10\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Nourish Tasting were a positive experience (n=14)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.755813953488373%\"\u003e\n \u003cp\u003e11(78.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.755813953488373%\"\u003e\n \u003cp\u003e3(21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.883720930232558%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.593023255813954%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.046511627906977%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.901162790697674%\"\u003e\n \u003cp\u003e1.2(0.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.294429708222812%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"92.70557029177719%\" colspan=\"10\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePart B) Engage\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.819628647214856%\" colspan=\"5\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eQ4\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Engage Lesson plans useful and appropriate for year group (n=11)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.753315649867375%\"\u003e\n \u003cp\u003eKS1 n=9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.814323607427056%\"\u003e\n \u003cp\u003e3(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.814323607427056%\"\u003e\n \u003cp\u003e6(66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.018567639257295%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.753315649867375%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.079575596816976%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.946949602122016%\"\u003e\n \u003cp\u003e1.7(0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.226452905811623%\"\u003e\n \u003cp\u003eKS2 n=2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.829659318637274%\"\u003e\n \u003cp\u003e1(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.829659318637274%\"\u003e\n \u003cp\u003e1(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.627254509018035%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.226452905811623%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.230460921843687%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.030060120240481%\"\u003e\n \u003cp\u003e1.5(0.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.819628647214856%\" colspan=\"5\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eQ5\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Engage Guide timings within lesson plans used accurate and appropriate (n=10)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.753315649867375%\"\u003e\n \u003cp\u003eKS1 n=8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.814323607427056%\"\u003e\n \u003cp\u003e3(37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.814323607427056%\"\u003e\n \u003cp\u003e4(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.018567639257295%\"\u003e\n \u003cp\u003e1(12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.753315649867375%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.079575596816976%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.946949602122016%\"\u003e\n \u003cp\u003e1.8(0.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.226452905811623%\"\u003e\n \u003cp\u003eKS2 n=2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.829659318637274%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.829659318637274%\"\u003e\n \u003cp\u003e2(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.627254509018035%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.226452905811623%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.230460921843687%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.030060120240481%\"\u003e\n \u003cp\u003e2(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.819628647214856%\" colspan=\"5\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eQ7\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Available resources within the Farm to Fork, Pleasure on a Plate and Food Futures topics appropriate and useful for year group (n=10)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.753315649867375%\"\u003e\n \u003cp\u003eKS1 n=8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.814323607427056%\"\u003e\n \u003cp\u003e2(25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.814323607427056%\"\u003e\n \u003cp\u003e6(75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.018567639257295%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.753315649867375%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.079575596816976%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.946949602122016%\"\u003e\n \u003cp\u003e1.8(0.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.226452905811623%\"\u003e\n \u003cp\u003eKS2 n=2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.829659318637274%\"\u003e\n \u003cp\u003e1(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.829659318637274%\"\u003e\n \u003cp\u003e1(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.627254509018035%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.226452905811623%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.230460921843687%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.030060120240481%\"\u003e\n \u003cp\u003e1.5(0.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.819628647214856%\" colspan=\"5\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eQ9\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Pupil reaction to Engage lessons was positive (n=11)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.753315649867375%\"\u003e\n \u003cp\u003eKS1 n=9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.814323607427056%\"\u003e\n \u003cp\u003e6(66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.814323607427056%\"\u003e\n \u003cp\u003e2(22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.018567639257295%\"\u003e\n \u003cp\u003e1(11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.753315649867375%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.079575596816976%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.946949602122016%\"\u003e\n \u003cp\u003e1.4(0.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.226452905811623%\"\u003e\n \u003cp\u003eKS2 n=2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.829659318637274%\"\u003e\n \u003cp\u003e1(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.829659318637274%\"\u003e\n \u003cp\u003e1(50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.627254509018035%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.226452905811623%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.230460921843687%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.030060120240481%\"\u003e\n \u003cp\u003e1.5(0.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.819628647214856%\" colspan=\"5\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eQ11\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;Engage speakers or visits useful and appropriate (n=11)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.753315649867375%\"\u003e\n \u003cp\u003eKS1 n=9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.814323607427056%\"\u003e\n \u003cp\u003e5(55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.814323607427056%\"\u003e\n \u003cp\u003e4(44.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.018567639257295%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.753315649867375%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.079575596816976%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.946949602122016%\"\u003e\n \u003cp\u003e1.4(0.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.226452905811623%\"\u003e\n \u003cp\u003eKS2 n=2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.829659318637274%\"\u003e\n \u003cp\u003e2(100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.829659318637274%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.627254509018035%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.226452905811623%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.230460921843687%\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.030060120240481%\"\u003e\n \u003cp\u003e1(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"7.294429708222812%\" colspan=\"12\" valign=\"top\" style=\"width: 99.8675%;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eNourish data reported as n (%) of participant (n\u003csub\u003emax\u003c/sub\u003e= 16) responses to the above statements\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eEngage\u0026nbsp;\u003c/em\u003e\u003cem\u003edata reported as n (%) of participant (nmax=11) responses to the above statements\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eNEQ data completed by teaching staff, principal/vice principal or reception staff \u0026ndash; i.e., school staff\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThematic analysis of Nourish and Engage qualitative data supports these findings as follows (\u003cstrong\u003eTable 7\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eWithin the NEQ, teachers reported that healthy snack provision was the most valuable element of the Nourish intervention and that Nourish had a positive effect by encouraging children to try new food items, with even \u0026lsquo;fussy\u0026rsquo; children consuming the snacks after observing their peers. Furthermore, teachers reported that trips to C1 and C2 were highly enjoyable and that Tasting Days encouraged children to try new foods and were delivered in an interactive way which instilled confidence and a sense of responsibility in children. The Nourish theme of \u0026lsquo;Useful canteen decorations\u0026rsquo; emerged, as most\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eteachers reported that delivery of canteen decorations (e.g. posters, bunting and tablecloths) was prompt and effortless and decorations were a useful addition to the school.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7:\u003c/strong\u003e Thematic analysis of qualitative Nourish and Engage intervention data\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"954\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003ePart A) Nourish\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.49317943336831%\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.331584470094437%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCodes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"61.17523609653725%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllustrative Quotes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.49317943336831%\"\u003e\n \u003cp\u003e\u003cem\u003ePupils enjoyed healthy snack provision\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.331584470094437%\"\u003e\n \u003cul\u003e\n \u003cli\u003eChildren enjoyed snacks\u003c/li\u003e\n \u003cli\u003eEncouraged tasting of new foods which children had not tried previous\u003c/li\u003e\n \u003cli\u003eHassle free prompt snack delivery\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEasy access packaging of snacks\u003c/li\u003e\n \u003cli\u003eSense of independence for children\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTime-consuming to butter toast \u0026ndash; but worth it\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"61.17523609653725%\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;The children really enjoyed their snack this week. It might interest you to know that, for a few, it was their first time tasting wheaten bread! It all went down very well\u0026rdquo; [School E P7 teacher]\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;Yes, the delivery took place promptly each Thursday and more than enough food for pupils provided\u0026rdquo; [School E principal]\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;They loved having their bread toasted and the independence of buttering their own/preparing their own snack.\u0026rdquo; [School J teacher]\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;When classroom assistant was there-easy to toast/butter etc. But very time consuming-lovely as a treat once a week\u0026rdquo; [School G teacher]\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.49317943336831%\"\u003e\n \u003cp\u003e\u003cem\u003eWell-organised and engaging tasting days\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.331584470094437%\"\u003e\n \u003cul\u003e\n \u003cli\u003eWell-organised\u003c/li\u003e\n \u003cli\u003eChildren enjoyed and engaged\u003c/li\u003e\n \u003cli\u003eEncouraged to try new food items\u003c/li\u003e\n \u003cli\u003eSense of responsibility\u003c/li\u003e\n \u003cli\u003eAge appropriate\u003c/li\u003e\n \u003cli\u003eAll children\u0026rsquo;s diets catered for\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"61.17523609653725%\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;Highly organized. Someone to meet us off the bus. Didn\u0026rsquo;t have to think of anything. Children were engaged throughout. Very worthwhile experience\u0026rdquo; [School G teaching staff]\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;The experiences gave the children a chance to prepare food together e.g. making sandwiches. It gave them a sense of responsibility.\u0026rdquo; [School G teacher]\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;Children shown video from FIP4, children all screamed \u0026lsquo;ahh\u0026rsquo; when chicks were on screen. MP staff told children they had lots of different flavours of chicken with them today but that they \u0026lsquo;mixed them up\u0026rsquo; so they needed pupils help to identify flavours. Children tried different flavours and had to guess e.g. plain chicken, BBQ, Sweet Chilli, Tikka Masala. Pupils very excited and shouted out answers/guesses for every flavour. Lots of hands up/interaction. Many pupils told me this was their favourite station\u0026rdquo; [DAIRE Research team member]\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.49317943336831%\"\u003e\n \u003cp\u003e\u003cem\u003eUseful canteen decorations\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.331584470094437%\"\u003e\n \u003cul\u003e\n \u003cli\u003eEasy and prompt delivery\u003c/li\u003e\n \u003cli\u003eEquipment and good addition to school\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"61.17523609653725%\" valign=\"top\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;The equipment provided to the canteen has been most welcome and put to immediate use\u0026rdquo;. [School E principal]\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;Delivery of canteen equipment was hassle free\u0026rdquo; [School E principal]\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;\u0026hellip; The canteen decorations will be an excellent addition to our canteen in the new school year and staff were delighted to receive them\u0026rdquo;. [School R teacher]\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003ePart B) Engage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.49317943336831%\"\u003e\n \u003cp\u003e\u003cem\u003eEnjoyable Engage topics, lessons and resources\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.331584470094437%\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Children enjoyed and engaged with interactive lessons and resources: videos, games, stories, songs, physical education lesson\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Accessible resources\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Age-appropriate\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"61.17523609653725%\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;Age appropriate, pupils engaged and enjoyed, informative [School D P3 teacher]\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;I liked that the resources were interactive and all links for online resources were easily accessible. The children enjoyed the story books and songs\u0026rdquo; [School O P3 teacher]\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;The videos and lesson plans were very informative and provided great introductions for each area and generated good discussions too!\u0026rdquo; [School G P3 teacher]\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;Fantastic enthusiasm-particularly Animal Welfare and Johnny Loves Milk. Children loved their PE lesson and stories from the Powerpoint\u0026rdquo; [School O P7 teacher]\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;Lots of excitement, P3 kids very engaged and excited, salmon and jellyfish game, all pupils responded well\u0026rdquo; [DAIRE research team observing physical education lesson]\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.49317943336831%\"\u003e\n \u003cp\u003e\u003cem\u003eQuestionable age-appropriateness for P3 children\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.331584470094437%\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Attention span of younger children\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Lessons too detailed and advanced\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"61.17523609653725%\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;Some videos were a little long for P3 children. The \u0026lsquo;Right Royal Fishy Tale\u0026rsquo; book was also a bit too long to hold my P3s attention throughout although they did love the storyline\u0026rdquo; [School R P3 teacher]\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;The resources and activities were appropriate and useful\u0026hellip;we found the Food Futures element harder to deliver as KS1 pupils aren\u0026rsquo;t as influenced by marketing etc\u0026hellip;some lessons needed to be simplified/adapted\u0026rdquo; \u0026ndash; [School G P3 teacher]\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.49317943336831%\"\u003e\n \u003cp\u003e\u003cem\u003eEngaging guest speakers, trips and visits\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.331584470094437%\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Children enjoyed and engaged\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Age-appropriate\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Informative\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Possible that money spent on trips was not worthwhile (\u003cem\u003eNote: only in one school\u003c/em\u003e)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"61.17523609653725%\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;All speakers were knowledgeable on their subjects and engaged the children\u0026rdquo; [School C P7 teacher]\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;Really engaged children-appropriate to age group. Great resources and follow up activities. Great to have a specialist to talk to children\u0026rdquo; [School G P3 teacher]\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;The Farm was amazing. The children thoroughly loved it. The staff engaged so well with the children\u0026rdquo; [School D Principal]\u003c/li\u003e\n \u003cli\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026ldquo;Address given incorrect..10 minute visit\u0026hellip;I just feel that the money spent on buses and the time spent travelling was a waste of funds which could have been spent elsewhere.\u0026rdquo; [School P Teacher]\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTeachers reported that interactive lessons and resources such as videos, games and the practical physical activity (Physical Education) lesson were the most popular aspects of Engage and that the \u003cem\u003eAnimal Welfare\u003c/em\u003e and \u003cem\u003eJohnny Loves Milk\u003c/em\u003e lessons were particularly favoured. Some concerns were raised in relation to lessons being too advanced and detailed when considering the attention span of younger children.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith respect to the Engage theme of, \u0026lsquo;Engaging guest speakers, trips and visits\u0026rsquo;, teachers emphasized that children enjoyed these Engage elements, finding them extremely informative and useful.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne theme which emerged consistently within both Nourish and Engage qualitative data was that the DAIRE intervention should be implemented across a full academic year. Most teachers commented on timing and planning pressures and this, combined with the fact that DAIRE did not begin until late into the second academic term, meant that delivery was rushed.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;There is a LOT of content. Need a whole school year to develop properly and do all lessons\u0026rdquo; [School P \u0026lsquo;Nourish and Engage\u0026rsquo; P3 teacher]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContamination\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo formal data were collected in relation to contamination but it is unlikely that contamination influenced the intervention and outcome data collection as a result of study design and randomization (Additional File 11).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMechanisms of Impact\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs interviews with pupils were not conducted, it was not possible to explore potential mediators of behaviour change or unanticipated pathways within this process evaluation. However,\u0026nbsp;thematic analysis of qualitative teacher responses within the NEQ and ETEQ allowed insight into pupil reaction and engagement with the interventions and exploration of possible DAIRE MOI.Two possible MOIs in relation to the Nourish intervention were identified (\u003cstrong\u003eTable 8\u003c/strong\u003e):\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eSocial learning\u003c/li\u003e\n \u003cli\u003eExperimental Learning (hands-on approach)\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eMost teachers reported that social learning and peer influence was key to healthy snack consumption, with pupils being more willing to try new foods and opting to consume the Nourish healthy snacks once they observed their peers doing so. \u0026nbsp;This may imply that Nourish elements such as Tasting Days and healthy snack provision may have produced the significant changes observed in the DAIRE trial in terms of increased willingness to try new foods through pupil bonding and shared learning.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Nourish intervention is also likely to have produced change by increasing pupils\u0026rsquo; knowledge about food and healthy food options through fun-based learning and experiences. Teachers commented in the NEQ that preparing healthy snacks and feeding back product preferences during Tasting Days influenced children\u0026rsquo;s awareness of healthy food options and helped instil a sense of responsibility and independence in children regarding their food intake and dietary choices.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMOI for Engage were explored as, although no statistical differences were observed regarding primary outcomes, teachers reported the benefits of Engage and commented on how it should be integrated into the school curriculum.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThematic analysis identified two possible MOI in relation to the Engage intervention (\u003cstrong\u003eTable 8\u003c/strong\u003e):\u003c/p\u003e\n\u003cp\u003e1. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Interactive engage content\u003c/p\u003e\n\u003cp\u003e2. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Real life connections\u003c/p\u003e\n\u003cp\u003eTeachers commented that the Engage topic and lesson content was interactive, stimulating and engaging for children and encouraged class discussions. The Engage intervention also allowed pupils to establish real life connections. Relating lessons to real life i.e., \u003cem\u003eAnimal Welfare\u003c/em\u003e lesson to the children\u0026rsquo;s pets, cooking a meal together, attending the pet farm and listening to guest speakers brought the Engage topic to life.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 8:\u003c/strong\u003e Mechanisms of change uncovered from NEQ and ETEQ data\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"1030\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003ePart A) Nourish\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.12621359223301%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMechanism of impact\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.194174757281555%\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow it worked\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"70.67961165048544%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllustrative Quotes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.12621359223301%\"\u003e\n \u003cp\u003e\u003cem\u003eSocial Learning\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.194174757281555%\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003ePeer influence\u003c/li\u003e\n \u003cli\u003ePupils imitate pupils\u003c/li\u003e\n \u003cli\u003eClass discussions\u003c/li\u003e\n \u003cli\u003ePreparing food together\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"70.67961165048544%\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003e\u0026ldquo;When given the wheaten bread/brown bread first a number of the children had never had before and didn\u0026rsquo;t try it but eventually most of them were eating it and really enjoying it. As often as possible we had the snack along with the P7-great peer tutoring opportunities.\u0026rdquo; [School L teacher]\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;The children became more independent at preparing their snacks, helping each other etc. and looked forward to the days snacks\u0026rdquo; [School J teaching staff]\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;The children looked forward to their snacks; even tasting wheaten bread for the first time and enjoying it! They enjoyed having toast in the classroom.. They shared out their fruit with each other if they didn\u0026rsquo;t fancy eating some of them.\u0026rdquo; [School G teacher]\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.12621359223301%\"\u003e\n \u003cp\u003e\u003cem\u003eFun-based learning\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.194174757281555%\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eIncreased knowledge of healthy food\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSense of independence and responsibility\u003c/li\u003e\n \u003cli\u003eChildren involved in decision making\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"70.67961165048544%\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003e\u0026ldquo;The healthy snacks encouraged healthy eating. The Tasting Day taught the children a lot and again encouraged healthy eating.\u0026rdquo; [School R teacher]\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;Children loved having the choice of their own snack. They loved having their bread toasted and the independence of preparing their own snack.\u0026rdquo; [School J teaching staff]\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;The experiences gave the children a chance to prepare food together e.g. making sandwiches. It gave them a sense of responsibility.\u0026rdquo; [School G teacher \u0026ndash; Regarding Tasting Day at C1]\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003ePart B) Engage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.12621359223301%\"\u003e\n \u003cp\u003e\u003cem\u003eInteractive engage content\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.194174757281555%\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eClass discussions\u003c/li\u003e\n \u003cli\u003eGroup work\u003c/li\u003e\n \u003cli\u003eInteractive lessons \u0026ndash; stories, songs, videos\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"70.67961165048544%\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003e\u0026ldquo;Really engaged children-appropriate to age group. Great resources and follow up activities. Great to have a specialist to talk to children.\u0026rdquo; [School G P3 teacher \u0026ndash; Regarding guest speakers] \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;Children loved planning their own menus and enjoyed presenting their ideas to the class. Lessons allowed for lots of group work and discussion. Everyone was included \u0026ndash; re Food Futures: Restaurant lesson\u0026rdquo; [School L P3 teacher] \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;Fantastic enthusiasm-particularly Animal Welfare and Johnny Loves Milk. Children loved discussions/debates. Children loved their PE lesson and stories from the PowerPoint\u0026rdquo; [School O P7 teacher] \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"9.12621359223301%\"\u003e\n \u003cp\u003e\u003cem\u003eReal life connections\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.194174757281555%\"\u003e\n \u003cul type=\"disc\"\u003e\n \u003cli\u003eRelate to real life scenarios\u003c/li\u003e\n \u003cli\u003eBrought DAIRE to life\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMemorable lessons and visits\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd width=\"70.67961165048544%\"\u003e\n \u003cul\u003e\n \u003cli\u003e\u0026ldquo;Children really liked making their own book as part of the \u0026lsquo;Food Scribblers\u0026rsquo; lesson. They are enjoying the Food Futures lessons and are excited to cook the meal chosen by the class. The visit of the travelling farm was one of their favourite parts\u0026rdquo; [School R P3 teacher]\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;Some children were able to contribute real life experiences due to family farm links\u0026rdquo; [School L P3 teacher]\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u0026ldquo;The children loved the Animal Welfare lesson and related it to how they look after their pets at home!\u0026rdquo; [School R P3 teacher]\u003c/li\u003e\n \u003c/ul\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eContext\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTeachers from 50% (n=4) of Nourish schools and teachers from 71.4% (n=5) of Engage schools reported experiencing barriers during intervention delivery. Thematic analysis of NEQ and ETEQ qualitative responses revealed that time was the biggest DAIRE barrier which, in turn is likely to have influenced the time to induce pupil change and, ultimately, the change in primary and secondary outcomes observed.\u0026nbsp;Teachers had to give priority to delivering the national curriculum and other school priorities and, as such, they reported\u0026nbsp;shortening lessons or not completing lessons due to time constraints:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Time was a major issue. With everything else needing to be taught it was difficult to fit it in\u0026rdquo; [School C Engage P3 teacher]\u003c/p\u003e\n\u003cp\u003eTeachers also reported that DAIRE should be planned well in advance of the school year to enable complete implementation. Overall PE findings detail the main barrier to DAIRE intervention implementation was time, which in turn was likely to have influenced the time to induce pupil change and, ultimately, the change in primary outcomes observed.\u003c/p\u003e\n\u003cp\u003eHowever findings on fidelity and dose, acceptability and MOI, suggested that guest speakers, the Mobile Petting Farm, healthy snack provision and Tasting Days were the most popular elements and the ones that had a notable positive influence. Such elements would be costly, therefore the removal of the cost barrier to DAIRE may be considered a facilitating factor. These findings are notable, as such factors must be retained and replicated in future delivery.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe follow-up questionnaire designed for school representatives (principals, teachers and/or caterers) were sent to all participating primary schools approximately 1 year after the end of the interventions and responses were received by 5 schools, giving a response rate of 33% (5 principals, 6 teachers and 3 caterers). Responses received were generally very positive and highlighted particularly beneficial aspects, including the popularity of the healthy snack provision, enhancement of healthy eating polices and introduction of a sensory eating component, also identifying time constraints as a barrier to implementation.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDAIRE findings reported by Brennan et al., (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) indicated that the Nourish food environment intervention produced more positive changes in emotional and behavioural wellbeing, food knowledge, cooking competence and dietary intake than the Engage food-education intervention in primary school children in an economically disadvantaged area in Northern Ireland. The aim of this study was to conduct a process evaluation to help elucidate why the Nourish intervention was more effective than the Engage intervention and inform any modifications for successful future UK-wide DAIRE rollout.\u003c/p\u003e \u003cp\u003eDAIRE had a 100% retention rate at both school and pupil-level which appears higher than seen in other school-based dietary interventions (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), although retention rates are often not reported in school-based diet/food environment process evaluations. Process evaluation results, along with teachers\u0026rsquo; follow-up feedback, indicated high levels of acceptability and engagement with both the Nourish and Engage interventions and these two factors have previously been identified as integral to intervention success (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Methods used to determine acceptability and contamination vary widely across the PE literature, so it is difficult to directly compare these elements; however DAIRE acceptability and risk of contamination also appears comparable with other process evaluation literature with no issues were identified for either element.\u003c/p\u003e \u003cp\u003eFindings on quality (fidelity) and quantity (dose) of DAIRE implementation revealed that Nourish schools implemented a higher mean intervention dose in comparison with Engage schools which may help explain its effectiveness when compared with Engage in terms of the primary and secondary outcomes. DAIRE implementation levels are comparable with those reported within other school-based interventions targeting fruit and vegetable consumption, physical activity, dietary behaviour and obesity prevention (range of 30\u0026ndash;97% reported) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Furthermore, although teachers reported making adaptations to both interventions, largely to reduce amount of content due to time pressures, it is difficult to get a sense of the extent of adaptations from the data collected. This is notable as Inchley et al., (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) reported that teachers feeling empowered to adapt interventions can enhance intervention effectiveness. In contrast, however, adaptations to Engage related to lesson reduction, may have influenced fidelity and could possibly have contributed to the lack of change produced in those randomised to the Engage intervention. Furthermore, it was not possible to consider fidelity of training materials given to teachers as part of DAIRE but would be of interest to explore this further in future in terms of more comprehensive teacher training in relation to intervention delivery.\u003c/p\u003e \u003cp\u003ePE results revealed the intervention elements most implemented required the least teacher effort. These results are in-line with process evaluation results of the Child and Adolescent Trial for Cardiovascular Health and High 5 school-based interventions, whereby more time-consuming activities were implemented less frequently by teachers in the classroom (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). A systematic review of the implementation of 24 school-based fruit and vegetable distribution interventions highlights the need for detailed implementation guidelines and training workshops for teachers to ensure high intervention fidelity (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The Engage resources in DAIRE included a video aimed at teachers, but more detailed guidance/training, alongside more time to plan how to introduce the programme into their classroom are likely to be of value.\u003c/p\u003e \u003cp\u003eThere were also varying levels of teacher engagement in relation to outcome assessment, although this is distinct from the intervention delivery. In contrast, PE findings regarding high pupil questionnaire response rate demonstrate the high level of engagement in relation to data collection in children which will be encouraging in relation to any future DAIRE rollout. Ultimately, stronger engagement with outcomes assessment could have resulted in more reliable conclusions regarding both primary and secondary DAIRE outcomes. Educational attainment data were also requested from participating schools but the limited data received from a small number of schools (n\u0026thinsp;=\u0026thinsp;5) were variable in format and did not allow for formal analysis, which highlights the need for standardisation of data collection methods in any future evaluation.\u003c/p\u003e \u003cp\u003eFour possible MOI: social learning and fun-based learning in relation to Nourish, interactive engaging content, and real-life connections in relation to Engage, were identified from process evaluation findings that help to explain how the Nourish intervention produced change. Fidelity, dose and acceptability results indicated that Nourish healthy snacks and Tasting Days, and Engage lessons involving story books, songs and process evaluation lessons, as well as Guest Speakers and the Mobile Petting Farm were the key DAIRE intervention elements. The majority of these identified key elements were delivered as part of the Nourish intervention specifically, which may explain its effectiveness compared with Engage in relation to the trial outcomes. These findings are comparable to process evaluation findings from other school-based interventions including Project Tomato, High 5 and EMPOWER, whereby the most popular pupil activities were interactive (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). In terms of ensuring intervention effectiveness and successful future UK-wide rollout, process evaluation findings suggest that an overall focus should be placed on retaining the key MOI, and ensuring DAIRE is interactive and easy to implement for teachers.\u003c/p\u003e \u003cp\u003eIt is evident from process evaluation results that lack of time was a key contextual barrier influencing DAIRE implementation and was most reported in relation to Engage, which relied more on teacher delivery. This finding is consistent with process evaluation findings from Christian et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) regarding Project Tomato (n\u0026thinsp;=\u0026thinsp;311 children aged 7 years in 24 schools) and Bere et al. (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) regarding Fruit and Vegetables Make the Marks (n\u0026thinsp;=\u0026thinsp;369 children, mean age 11.9 years, in 9 schools); whereby low implementation levels and little difference in children\u0026rsquo;s dietary intake was observed in schools as a result of intervention materials requiring too much preparation time. Process evaluation identified that teachers felt that DAIRE should be implemented across the full academic year and be integrated into the school curriculum. Similarly, previous process evaluation studies of the We Act and the Active for Life Year 5 primary school-based interventions, reported integration of intervention content into the curriculum as a possibility to improve implementation and outcomes (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). DAIRE Engage intervention content was mapped to the NI curriculum, but as already discussed, planning time for teachers is likely to have been limited so this should be built into any further rollout.\u003c/p\u003e \u003cp\u003eOriginally it was planned for Nourish to include more of a focus on canteens and food served rather than food presentation, however, procurement regulations within schools and the need to adhere to food standards precluded this within the timeframe. It is likely that influencing procurement chains within school systems would be challenging as contracts are typically already in place so it is important to be aware of these potential challenges when designing future studies. Catering staff feedback suggested issues with limited time to prepare food and time allocated for pupils to eat the food, therefore these considerations need to be built into any rollout of the programme.\u003c/p\u003e \u003cp\u003eAlthough statistically significant effects on primary outcomes were not demonstrated by Engage, it may have been due to its more limited implementation, as although 100% of Engage schools delivered core elements of Engage, mean delivery was 50% of the overall engage intervention elements, largely due to teacher time pressures. Furthermore, the research aimed to conduct with trial with ecological validity, where possible, but it was not feasible in terms of time and funding to translate all Engage intervention resources in the event Irish language schools were randomized to the Engage arm of the trial and this may be an important consideration in any future roll-out in regions where different languages are necessary. However, in order to achieve a whole-school approach and its prospective benefits to children\u0026rsquo;s diet quality and nutritional knowledge, the Engage education intervention should be considered for retention in any future DAIRE rollout. This may induce a sense of community amongst pupils, ensure consistency in the healthy eating messages both within and outside of the classroom; key here is making the lessons fun and memorable for participating children, whilst also extending their knowledge.\u003c/p\u003e \u003cp\u003eThis process evaluation has several strengths. It followed the recently updated MRC guidance and employed a comprehensive mixed-methods approach to evaluate all three framework elements. Due to prior planning, process-evaluation-specific tools and questionnaires were developed and used throughout the DAIRE intervention. Also, due to the large volume of DAIRE PE data collected, merging of data sources occurred, after discussion with the research team, to enable the most effective interpretation and use of data collected in terms of data quality and relevance for each aspect of process evaluation. A number of factors reduced the likelihood of contamination of control participants in this trial, including whole school rather than class randomization and adequate training and experience of the DAIRE research team when carrying out data collection in control schools. Therefore, it is unlikely that contamination influenced any of the DAIRE primary or secondary outcomes observed (Additional File 10).\u003c/p\u003e \u003cp\u003eIn terms of limitations, data collected from teachers that completed the process evaluation questionnaires may not be representative of all teachers who were involved in the implementation of DAIRE. Furthermore, there is potential for bias in data collection as some of the researchers involved in main study outcome data collection were involved in process evaluation data collection. The researcher leading the initial process evaluation analysis was not involved in the DAIRE trial in any way, but researchers involved in the trial reviewed and commented on the final process evaluation manuscript. Additionally, no direct pupil feedback regarding the DAIRE intervention exists. Planned follow-up teacher phone calls and interviews were not possible due to the COVID-19 pandemic, therefore no data on DAIRE intervention sustainability were collected and triangulation of DAIRE PE results was not possible. In addition to this, the majority of school principals did not respond to requests for the DAIRE research team to attend to conduct Nourish and Engage process evaluation-related observations, therefore observations were limited.\u003c/p\u003e \u003cp\u003eWithin this process evaluation, data on mediating and moderating factors were not collected and the process evaluation findings did not elicit, for example, understanding of why health-related quality of life significantly improved in males randomised to Nourish significantly compared with those who did not receive Nourish in subgroup analyses (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Therefore, future work exploring mediating and moderating factors may be informative in terms of interpreting these findings. Finally, process evaluation was completed following the main DAIRE study outcomes being published; thus biased interpretation is possible. However, as initial process evaluation analysis was undertaken independently by a researcher who was not directly involved with the DAIRE implementation and in-person data collection, the likelihood of this is reduced.\u003c/p\u003e \u003cp\u003eGaps for future DAIRE research identified from this process evaluation include: sourcing a sustainable funding and resourcing mechanism for future rollout, including a range of funding models and the role of the private sector. Incorporation of a \u0026lsquo;family\u0026rsquo; and/or community aspect to the interventions to fully achieve a whole-school approach should also be considered. Overall, it is likely that DAIRE intervention success is generalisable to UK-wide primary schools and beyond, due to the comparable structures within the primary school education system, therefore process evaluation findings can help to inform the plan and design of future similar effective interventions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the DAIRE PE yielded several important findings related to the implementation, MOI and contextual factors influencing DAIRE intervention effectiveness and outcomes and helped to elucidate why Nourish produced more positive changes in outcomes than the Engage intervention. The most effective elements of the interventions which should be maintained in any future rollout include provision of interactive and engaging intervention elements at no financial cost to the school. Findings also identified suggestions for improvement including provision of increased teacher training, support and planning time, content reduction to facilitate easy integration into the existing school curriculum, and implementation across the full academic year.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMOI: Mechanisms of impact\u003c/p\u003e\n\u003cp\u003eMRC: Medical Research Council\u003c/p\u003e\n\u003cp\u003eHRQOL: Health-related Quality of Life\u003c/p\u003e\n\u003cp\u003eNEQ: Nourish Evaluation Questionnaire\u003c/p\u003e\n\u003cp\u003eETEQ: Engage Teacher Evaluation Questionnaire\u003c/p\u003e\n\u003cp\u003eNOT: Nourish Observation Tool\u003c/p\u003e\n\u003cp\u003eEOT: Engage Observation Tool\u003c/p\u003e\n\u003cp\u003eSDQ: Strength and Difficulties\u003c/p\u003e\n\u003cp\u003eKS: Key Stage\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the main DAIRE trial was obtained from The School of Social Sciences, Education and Social Work Ethics Committee, Queen\u0026rsquo;s University Belfast (Reference number 038_1819). Parental informed consent was obtained for all pupils who participated in this trial. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe main trial was funded by Agri-Food Quest Competence Centre, funded by Invest Northern Ireland. The study funder had no role in the study design, collection, analysis or interpretation of the data and had no role in writing the manuscript. No further funding was required to complete the process evaluation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNA drafted the manuscript, with input from SFB and JVW. All authors read and approved the final manuscript. In relation to the Daire trial, JVW was the Chief Investigator, formulated the research question, designed the trial and directed the research activities. MD, DMC, MCMK, PMC, CE, RFH, LD, NEOC, and CRC advised on aspects of the study design and implementation. SFB, SEM and FL were involved in intervention delivery and data collection. \u0026nbsp;All author(s) and industry partners that were involved in delivery of the DAIRE trial read and approved the final manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank the pupils, principals, teachers and caterers from all the schools that participated in the project or were involved in the development of the resources. The authors are grateful for the support received from the local food industry partners, visiting experts from Queen\u0026rsquo;s University Belfast and personnel from Further Education Colleges during the implementation of the trial. The authors would also like to thank Mrs. Clare Jess for her assistance with the administration of the trial.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGaziano JM. When should heart disease prevention begin? N Engl J Med. 1998;338(23):1690\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLake AA, Mathers JC, Rugg-Gunn AJ, Adamson AJ. Longitudinal change in food habits between adolescence (11\u0026ndash;12 years) and adulthood (32\u0026ndash;33 years): the ASH30 Study. J Public Health. 2006;28(1):10\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePopkin BM, Gordon-Larsen P. The nutrition transition: worldwide obesity dynamics and their determinants. International Journal of Obesity and Related Metabolic Disorders [Online]. 2004;28(Suppl 3):S2-9. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nature.com/articles/0802804\u003c/span\u003e\u003cspan address=\"https://www.nature.com/articles/0802804\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [Accessed: December 13th 2021].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoodside JV, Adamson A, Spence S, Baker T, McKinley MC. Opportunities for intervention and innovation in school food within UK schools. Public Health Nutr. 2021;24(8):2313\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeichselbaum E, Buttriss JL. Diet, nutrition and school children: an update. Nutr Bull. 2014;39(1):9\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang D, Stewart D. The implementation and effectiveness of school-based nutrition promotion programmes using a health-promoting schools approach: a systematic review. Public Health Nutr. 2013;16(6):1082\u0026ndash;100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrennan SF, Lavelle F, Moore SE, Dean M, McKinley MC, McCole P, et al. Food environment intervention improves food knowledge, wellbeing and dietary habits in primary school children: Project Daire, a randomised-controlled, factorial design cluster trial. Int J Behav Nutr Phys Activity. 2021;18(1):23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance, British Medical Journal, 374, n2061. 2021;473:n2061. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1136/bmj.n\u003c/span\u003e\u003cspan address=\"10.1136/bmj.n\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e2061 [Accessed: 8th October 2021].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350:h1258.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGlasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9):1322\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoodman R. The Strengths and Difficulties Questionnaire: A Research Note. J Child Psychol Psychiatry. 1997;38(5):581\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRavens-Sieberer U, Gosch A, Erhart M, von Rueden U, Nickel J, Kurth B-M, et al. The KIDSCREEN Group Europe. The KIDSCREEN Questionnaires. Quality of Life Questionnaires for Children and Adolescents. Volume 49525. Lengerich: Pabst Science Publishers; 2006. [Available from: www.kidscreen.org.].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance, British Medical Journal, 374, n2061. 2021;473:n2061. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1136/bmj.n\u003c/span\u003e\u003cspan address=\"10.1136/bmj.n\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e2061 [Accessed: 8th October 2021].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJunkin A. What is the association between school based nutrition interventions and children\u0026rsquo;s health beliefs: An analysis of secondary data from the DAIRE project [MPH thesis]. Belfast: Queen\u0026rsquo;s University Belfast; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350:h1258.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh AS, Chinapaw MJM, Brug J, Van Mechelen W. Process evaluation of a school-based weight gain prevention program: the Dutch Obesity Intervention in Teenagers (DOiT). Health Educ Res. 2009;24(5):772\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLytle LA, Murray DM, Perry CL, Story M, Birnbaum AS, Kubik MY, et al. School-based approaches to affect adolescents' diets: results from the TEENS study. Health Educ Behav. 2004;31(2):270\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJago R, Rawlins E, Kipping RR, Wells S, Chittleborough C, Peters TJ, et al. Lessons learned from the AFLY5 RCT process evaluation: implications for the design of physical activity and nutrition interventions in schools. BMC Public Health. 2015;15(1):946.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampbell R, Rawlins E, Wells S, Kipping RR, Chittleborough CR, Peters TJ, et al. Intervention fidelity in a school-based diet and physical activity intervention in the UK: Active for Life Year 5. Int J Behav Nutr Phys Activity. 2015;12(1):141.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMathews LB, Moodie MM, Simmons AM, Swinburn BA. The process evaluation of It's Your Move! an Australian adolescent community-based obesity prevention project. BMC Public Health. 2010;10(1):448.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavis M, Baranowski T, Resnicow K, Baranowski J, Doyle C, Smith M, et al. Gimme 5 fruit and vegetables for fun and health: process evaluation. Health Educ Behav. 2000;27(2):167\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteckler A, Ethelbah B, Martin CJ, Stewart D, Pardilla M, Gittelsohn J, et al. Pathways process evaluation results: a school-based prevention trial to promote healthful diet and physical activity in American Indian third, fourth, and fifth grade students. Prev Med. 2003;37(6):80\u0026ndash;S90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaranowski T, Davis M, Resnicow K, Baranowski J, Doyle C, Lin LS, et al. Gimme 5 fruit, juice, and vegetables for fun and health: outcome evaluation. Health Educ Behav. 2000;27(1):96\u0026ndash;111.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerry CL, Bishop DB, Taylor G, Murray DM, Mays RW, Dudovitz BS, et al. Changing fruit and vegetable consumption among children: the 5-a-Day Power Plus program in St. Paul, Minnesota. Am J Public Health. 1998;88(4):603\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdmundson EW, Luton SC, McGraw SA, Kelder SH, Layman AK, Smyth MH, et al. CATCH: classroom process evaluation in a multicenter trial. Health Educ Q. 1994;Suppl(2):27\u0026ndash;S50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInchley J, Muldoon J, Currie C. Becoming a health promoting school: evaluating the process of effective implementation in Scotland. Health Promot Int. 2007;22(1):65\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReynolds KD, Franklin FA, Leviton LC, Maloy J, Harrington KF, Yaroch AL, et al. Methods, results, and lessons learned from process evaluation of the high 5 school-based nutrition intervention. Health Educ Behav. 2000;27(2):177\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsmail MR, Seabrook JA, Gilliland JA. Outcome evaluation of fruits and vegetables distribution interventions in schools: a systematic review and meta-analysis. Public Health Nutr. 2021;24(14):4693\u0026ndash;705.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLepe S, Goodwin J, Mulligan KT, Balestracci K, Sebelia L, Greene G. Process Evaluation of a Policy, Systems, and Environmental Change Intervention in an Urban School District. J Nutr Educ Behav. 2019;51(3):307\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristian MS, Evans CE, Ransley JK, Greenwood DC, Thomas JD, Cade JE. Process evaluation of a cluster randomised controlled trial of a school-based fruit and vegetable intervention: Project Tomato. Public Health Nutr. 2012;15(3):459\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBere E, Veier\u0026oslash;d MB, Bjelland M, Klepp KI. Outcome and process evaluation of a Norwegian school-randomized fruit and vegetable intervention: Fruits and Vegetables Make the Marks (FVMM). Health Educ Res. 2006;21(2):258\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBonde AH, Stjernqvist NW, Sabinsky MS, Maindal HT. Process evaluation of implementation fidelity in a Danish health-promoting school intervention. BMC Public Health. 2018;18(1):1407.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Process evaluation, School, Children, Diet, Food, Education, Childhood wellbeing, Child behaviour, Food environment, Whole-school approach","lastPublishedDoi":"10.21203/rs.3.rs-3757991/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3757991/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe Project\u003cstrong\u003e \u003c/strong\u003eDAIRE trial aimed to improve children’s health-related quality of life, wellbeing, food knowledge and dietary habits via two multi-component interventions: Nourish, and Engage. Nourish was an intervention aiming to alter the school food environment, provide food-based experiences and expose pupils to locally produced foods. Engage was an age-appropriate cross-curricular food education intervention incorporating food, agriculture, nutrition science and related careers. The purpose of this study was to conduct a mixed methods process evaluation to evaluate DAIRE implementation, mechanisms of impact (MOI) and context, and inform scalable implementation of the DAIRE approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The Medical Research Council’s (MRC) framework for process evaluation was followed. Formal and informal methods were used to collect quantitative and qualitative data during the DAIRE trial in relation to process evaluation. Quantitative data were analysed using descriptive statistics and qualitative data via thematic analysis to identify key themes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Fifteen schools and 983 pupils (n=495 Key Stage 1 (KS1) and n=488 Key Stage 2 (KS2) pupils) were recruited for the 6-month DAIRE intervention; a 100% retention rate was observed at the school level and the interventions had a high level of acceptability. Nourish schools implemented a higher mean intervention dose (57.2%) than Engage (50%) schools but, overall, mixed implementation of both interventions occurred. DAIRE produced change through four key MOI: social learning, experimental learning, interactive engaging content and real-life connections. Lack of time was the main contextual barrier to DAIRE implementation and lack of financial cost to schools was indicated as a potential facilitator.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e This process evaluation helped to identify important findings related to implementation, MOI and context. \u0026nbsp;The most effective elements of the interventions which should be maintained include provision of interactive and engaging intervention elements and ensure these are at no financial cost to the school. Findings also identified suggestions for improvement including provision of increased teacher training, support and planning time, content reduction to facilitate easy integration into the school curriculum, and implementation across the full academic year. A sustainable funding and resourcing mechanism is required for successful future roll-out.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration\u003c/strong\u003e: The original trial referenced in this process evaluation is registered as follows: National Institute of Health (NIH) U.S. National Library of Medicine Clinical Trials.gov (ID: NCT04277312)\u003c/p\u003e","manuscriptTitle":"Process evaluation of Project Daire: a food environment intervention that impacted food knowledge, wellbeing and dietary habits of primary school children","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-05 18:23:04","doi":"10.21203/rs.3.rs-3757991/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-25T13:32:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-24T10:27:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-18T14:53:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-15T22:31:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7218244117497041367552837287217525656","date":"2024-06-10T08:46:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"161949849781567542188325167076384843355","date":"2024-06-09T07:01:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"128910166596014681438114203515448745437","date":"2024-06-08T16:59:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-02T16:00:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217660698568264330089861444278874188324","date":"2024-05-27T16:24:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-27T09:14:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-02T06:25:20+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-01-03T11:25:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-03T11:23:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2023-12-15T09:57:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"32200a38-8f6f-461c-b332-59f2a9cd9cc8","owner":[],"postedDate":"January 5th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-10T16:01:42+00:00","versionOfRecord":{"articleIdentity":"rs-3757991","link":"https://doi.org/10.1186/s12889-025-21628-4","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-02-06 15:57:27","publishedOnDateReadable":"February 6th, 2025"},"versionCreatedAt":"2024-01-05 18:23:04","video":"","vorDoi":"10.1186/s12889-025-21628-4","vorDoiUrl":"https://doi.org/10.1186/s12889-025-21628-4","workflowStages":[]},"version":"v1","identity":"rs-3757991","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3757991","identity":"rs-3757991","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}