Use Of Process Evaluations Research Articles

Evaluation process use in the University Capacity Development Programme at Walter Sisulu University, South Africa

Background: The higher education (HE) policy framework identifies funding inter alia as one of the steering mechanisms, for the transformation of HE in South Africa. However, the role of monitoring and evaluation (ME) in facilitating this transformation is still emerging. While the instrumental use of evaluation findings is common, research on how process use can also play a critical role in facilitating sector change is missing.Objectives: The study investigated the use of process evaluations in enhancing the performance of the University Capacity Development Grant in a previously disadvantaged institution in the Eastern Cape province.Method: Purposive sampling was used as a method to select the participants. The case study design, interpretive paradigm and qualitative methods approach were adopted, and data were collected through individual semi-structured interviews, focus groups and document review. The study sampled 17 participants, including the Department of Higher Education and Training officials, the University Capacity Development Programme (UCDP) management and two staff focus groups.Results: If process use is to be strengthened, the evaluation process must be highly adaptable to specific programmatic circumstances and organisational contexts.Conclusion: Evaluation process use, in its practical form, must go beyond issues of participation from an individual perspective and include organisational and stakeholder management for effective implementation.Contribution: The study’s results are pivotal as they would assist different organisations worldwide that are running similar projects as the UCDP but have not yet understood the benefits that would be obtained by key stakeholders involved in an evaluation process.

91 The use of process evaluations in physical activity interventions for older adults: a systematic review

Abstract Background and purpose Development of effective physical activity interventions for older adults is important in eliciting positive health and well-being outcomes. Process evaluations of interventions are important in understanding implementation, mechanisms of impact and contextual factors that may influence these outcomes. However, it is unclear whether process evaluation frameworks are rigourously applied to physical activity interventions with older adults, particularly in relation to Medical Research Council (MRC) process evaluation guidance. This study aimed to systematically review the application and reporting of process evaluations of physical activity interventions for older adults against MRC process evaluation guidance. Methods MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, SPORTDiscus, OpenGrey, ProQuest Dissertations & Theses Database (PQDT) databases were searched. Process evaluation studies of physical activity interventions for older adults which measured at least two key MRC domains of implementation, mechanisms of impact and context were included. Two authors completed independent screening of title, abstract and full-text articles. A bespoke coding frame was developed to map and extract methods and findings on to key MRC process evaluation domains. Given the qualitative nature of the data, a narrative synthesis approach was undertaken. Results 17,002 studies were identified in the search, of which 27 were included. After mapping the methods of included studies against key domains of the coding framework; 21 assessed implementation, 27 assessed mechanisms of impact and 12 assessed context. 16 interventions reported the use of a process evaluation framework, 15 cited the use of a theoretical behavioural model and 7 reported the application of a logic model in intervention design. There were substantial differences in both the extent and quality of process evaluation methods. Such disparities were shaped in part by variations in the application of theoretical models and frameworks. Conclusions When mapping the included studies against MRC process evaluation guidelines, this review presented inconsistencies in how process evaluations have been reported and findings suggest a lack of methodological rigour. Findings highlight the need to extend the scope and quality of process evaluations of physical activity interventions for older adults.

Enhancing potential impact of hospital discharge interventions for patients with COPD: a qualitative systematic review

BackgroundPatients with chronic obstructive pulmonary disease (COPD) are frequently readmitted to hospital resulting in avoidable healthcare costs. Many different interventions designed to reduce hospital readmissions are reported with limited evidence for effectiveness. Greater insight into how interventions could be better designed to improve patient outcomes has been recommended.AimTo identify areas for optimisation within previously reported interventions provided to reduce COPD rehospitalisation to improve future intervention development.MethodsA systematic review was conducted by searching Medline, Embase, CINAHL, PsycINFO, and CENTRAL in June 2022. Inclusion criteria were interventions provided to patients with COPD in the transition from hospital to home or community. Exclusion criteria were lack of empirical qualitative results, reviews, drug trials, and protocols. Study quality was assessed using the Critical Appraisal Skills Programme tool and results were synthesised thematically.ResultsA total of 2,962 studies were screened and nine studies included. Patients with COPD experience difficulties when transitioning from hospital to home. It is therefore important for interventions to facilitate a smooth transition process and give appropriate follow-up post-discharge. Additionally, interventions should be tailored for each patient, especially regarding information provided.ConclusionVery few studies specifically consider processes underpinning COPD discharge intervention implementation. There is a need to recognise that the transition itself creates problems, which require addressing, before introducing any new intervention. Patients report a preference for interventions to be individually adapted—in particular the provision of patient information. Whilst many intervention aspects were well received, feasibility testing may have enhanced acceptability. Patient and public involvement may address many of these concerns and greater use of process evaluations should enable researchers to learn from each other’s experiences.Trial registrationThe review was registered in PROSPERO with registration number CRD42022339523.

Process evaluation of complex interventions in non-communicable and neglected tropical diseases in low- and middle-income countries: a scoping review

ObjectivesThe aim of this review is to map out the use of process evaluation (PE) in complex interventions that address non-communicable diseases (NCDs) and neglected tropical diseases (NTDs) to identify...

Function focused care in hospital: A mixed-method feasibility study.

During hospitalization patients frequently have a low level of physical activity, which is an important risk factor for functional decline. Function Focused Care (FFC) is an evidence-based intervention developed in the United States to prevent functional decline in older patients. Within FFC, nurses help older patients optimally participate in functional and physical activity during all care interactions. FFC was adapted to the Dutch Hospital setting, which led to Function Focused Care in Hospital (FFCiH). FFCiH consists of four components: (1) 'Environmental and policy assessment'; (2) 'Education'; (3) 'Goal setting with the patient' and (4) 'Ongoing motivation and mentoring'. The feasibility of FFCiH in the Dutch hospital setting needs to be assessed. Introduce FFCiH into Dutch hospital wards, to assess the feasibility of FFCiH in terms of description of the intervention, implementation, mechanisms of impact, and context. Mixed method design. A Neurological and a Geriatric ward in a Dutch Hospital. 56 Nurses and nursing students working on these wards. The implementation process was described and the delivery was studied in terms of dose, fidelity, adaptions, and reach. The mechanisms of impact were studied by the perceived facilitators and barriers to the intervention. Qualitative data were collected via focus group interviews, observations, and field notes. Quantitative data were collected via evaluation forms and attendance/participation lists. A detailed description of FFCiH in terms of what, how, when, and by whom was given. 54 Nurses (96.4%) on both wards attended at least 1 session of the education or participated in bedside teaching. The nurses assessed the content of the education sessions with a mean of 7.5 (SD 0.78) on a 0-10 scale. The patient files showed that different short and long-term goals were set. Several facilitators and barriers were identified, which led to additions to the intervention. An important facilitator was that nurses experienced FFCiH as an approach that fits with the principles underpinning their current working philosophy. The experienced barriers mainly concern the implementation elements of the FFCiH-components 'Education' and 'Ongoing motivation and mentoring'. Optimizing the team involvement, improving nursing leadership during the implementation, and enhancing the involvement of patients and their family were activities added to FFCiH to improve future implementation. FFCiH is feasible for the Dutch hospital setting. Strong emphasis on team involvement, nursing leadership, and the involvement of patients and their families is recommended to optimize future implementation of FFCiH in Dutch hospitals.What is already known•Function Focused Care is an evidence-based intervention that prevents functional decline among hospitalized elderly;•It is proven to be effective in assistant living facilities, nursing homes, home care, and acute care settings in the United States;•It is unknown if the intervention can be implemented in the Dutch Hospital Setting.What this paper adds•This study showed the feasibility of Function Focused Care in Hospital and the challenges in some elements of the intervention;•Optimizing the team involvement, improving nursing leadership during the implementation, and enhancing the involvement of patients and their family were added to FFCiH to improve future implementation.•This feasibility study can guide the use of process evaluation in examining the feasibility of an intervention in daily practice.

Process evaluation of complex interventions in chronic and neglected tropical diseases in low- and middle-income countries\u2014a scoping review protocol

BackgroundThe use of process evaluations is a growing area of interest in research groups working on complex interventions. This methodology tries to understand how the intervention was implemented to inform policy and practice. A recent systematic review by Liu et al. on process evaluations of complex interventions addressing non-communicable diseases found few studies in low- and middle- income countries (LMIC) because it was restricted to randomized controlled trials, primary healthcare level and non-communicable diseases. Yet, LMICs face different barriers to implement interventions in comparison to high-income countries such as limited human resources, access to health care and skills of health workers to treat chronic conditions especially at primary health care level. Therefore, understanding the challenges of interventions for non-communicable diseases and neglected tropical diseases (diseases that affect poor populations and have chronic sequelae) will be important to improve how process evaluation is designed, conducted and used in research projects in LMICs. For these reasons, in comparison to the study of Liu et al., the current study will expand the search strategy to include different study designs, languages and settings.ObjectiveMap research using process evaluation in the areas of non-communicable diseases and neglected tropical diseases to inform the gaps in the design and conduct of this type of research in LMICs.MethodsScoping review of process evaluation studies of randomized controlled trials (RCTs) and non-RCTs of complex interventions implemented in LMICs including participants with non-communicable diseases or neglected tropical diseases and their health care providers (physicians, nurses, technicians and others) related to achieve better health for all through reforms in universal coverage, public policy, service delivery and leadership. The aspects that will be evaluated are as follows: (i) available evidence of process evaluation in the areas of non-communicable diseases and neglected tropical diseases such as frameworks and theories, (ii) methods applied to conduct process evaluations and (iii) gaps between the design of the intervention and its implementation that were identified through the process evaluation. Studies published from January 2008. Exclusion criteria are as follows: not peer reviewed articles, not a report based on empirical research, not reported in English or Spanish or Portuguese or French, reviews and non-human research.DiscussionThis scoping review will map the evidence of process evaluations conducted in LMICs. It will also identify the methods they used to collect and interpret data, how different theories and frameworks were used and lessons from the implementation of complex interventions. This information will allow researchers to conduct better process evaluations considering special characteristics from countries with limited human resources, scarce data available and limited access to health care.

Systematic review of the use of process evaluations in knowledge translation research

BackgroundExperimental designs for evaluating knowledge translation (KT) interventions can provide strong estimates of effectiveness but offer limited insight into how the intervention worked. Consequently, process evaluations have been used to explore the causal mechanisms at work; however, there are limited standards to guide this work. This study synthesizes current evidence of KT process evaluations to provide future methodological recommendations.MethodsPeer-reviewed search strategies were developed by a health research librarian. Studies had to be in English, published since 1996, and were not excluded based on design. Studies had to (1) be a process evaluation of a KT intervention study in primary health, (2) be a primary research study, and (3) include a licensed healthcare professional delivering or receiving the intervention. A two-step, two-person hybrid screening approach was used for study inclusion with inter-rater reliability ranging from 94 to 95%. Data on study design, data collection, theoretical influences, and approaches used to evaluate the KT intervention, analysis, and outcomes were extracted by two reviewers. Methodological quality was assessed with the Mixed Methods Appraisal Tool (MMAT).ResultsOf the 20,968 articles screened, 226 studies fit our inclusion criteria. The majority of process evaluations used qualitative forms of data collection (43.4%) and individual interviews as the predominant data collection method. 72.1% of studies evaluated barriers and/or facilitators to implementation. 59.7% of process evaluations were stand-alone evaluations. The timing of data collection varied widely with post-intervention data collection being the most frequent (46.0%). Only 38.1% of the studies were informed by theory. Furthermore, 38.9% of studies had MMAT scores of 50 or less indicating poor methodological quality.ConclusionsThere is widespread acceptance that the generalizability of quantitative trials of KT interventions would be significantly enhanced through complementary process evaluations. However, this systematic review found that process evaluations are of mixed quality and lack theoretical guidance. Most process evaluation data collection occurred post-intervention undermining the ability to evaluate the process of implementation. Strong science and methodological guidance is needed to underpin and guide the design and execution of process evaluations in KT science.RegistrationThis study is not registered with PROSPERO.

Facebook Groups for the Management of Chronic Diseases.

The use of Facebook groups by health care researchers and professionals for chronic disease management, namely type 2 diabetes mellitus and coronary heart disease, is in its early stages and challenges are emerging. While Facebook groups offer great potential to deliver health support, research of Facebook groups for chronic disease management remains in its infancy, with robust evidence not yet available. Designing Facebook groups that are acceptable to users, health care researchers as well as health care professionals is a challenge, and there is a poor fit with traditional research and evaluation methods. Key recommendations for future research of Facebook groups for chronic disease management include: (1) iterative content development with input from the target patient population; (2) further understanding of the potential role of group “champions”; (3) ensuring the social media policies of health care institutions allow for real time online communication; and (4) utilizing comprehensive evaluation strategies, including the use of process evaluations.

Examining the use of process evaluations of randomised controlled trials of complex interventions addressing chronic disease in primary health care-a systematic review protocol.

BackgroundRandomised controlled trials (RCTs) of complex interventions in primary health care (PHC) are needed to provide evidence-based programmes to achieve the Declaration of Alma Ata goal of making PHC equitable, accessible and universal and to effectively address the rising burden from chronic disease. Process evaluations of these RCTs can provide insight into the causal mechanisms of complex interventions, the contextual factors, and inform as to whether an intervention is ineffective due to implementation failure or failure of the intervention itself. To build on this emerging body of work, we aim to consolidate the methodology and methods from process evaluations of complex interventions in PHC and their findings of facilitators and barriers to intervention implementation in this important area of health service delivery.MethodsSystematic review of process evaluations of randomised controlled trials of complex interventions which address prevalent major chronic diseases in PHC settings. Published process evaluations of RCTs will be identified through database and clinical trial registry searches and contact with authors. Data from each study will be extracted by two reviewers using standardised forms. Data extracted include descriptive items about (1) the RCT, (2) about the process evaluations (such as methods, theories, risk of bias, analysis of process and outcome data, strengths and limitations) and (3) any stated barriers and facilitators to conducting complex interventions. A narrative synthesis of the findings will be presented.DiscussionProcess evaluation findings are valuable in determining whether a complex intervention should be scaled up or modified for other contexts. Publishing this protocol serves to encourage transparency in the reporting of our synthesis of current literature on how process evaluations have been conducted thus far and a deeper understanding of potential challenges and solutions to aid in the implementation of effective interventions in PHC beyond the research setting.Systematic review registrationPROSPERO CRD42016035572Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-016-0314-5) contains supplementary material, which is available to authorized users.

A protocol for a systematic review of the use of process evaluations in knowledge translation research.

BackgroundExperimental designs for evaluating knowledge translation (KT) interventions for professional behavior change can provide strong estimates of intervention effectiveness but offer limited insight how the intervention worked or not. Furthermore, trials provide little insight into the ways through which interventions lead to behavior change and how they are moderated by different facilitators and barriers. As a result, the ability to generalize the findings from one study to a different context, organization, or clinical problem is severely compromised. Consequently, researchers have started to explore the causal mechanisms in complementary studies (process evaluations) alongside experimental designs for evaluating KT interventions. This study focuses on improving process evaluations by synthesizing current evidence on process evaluations conducted alongside experimental designs for evaluating KT interventions.Methods/DesignA medical research librarian will develop and implement search strategies designed to identify evidence that is relevant to process evaluations in health research. Studies will not be excluded based on design. Included studies must contain a process evaluation component aimed at understanding or evaluating a KT intervention targeting professional behavior change. Two reviewers will perform study selection, quality assessment, and data extraction using standard forms. Disagreements will be resolved through discussion or third party adjudication. Data to be collected include study design, details about data collection approaches and types, theoretical influences, approaches to evaluate intervention dose delivered, intervention dose received, intervention fidelity, intervention reach, data analysis, and study outcomes. This study is not registered with PROSPERO.DiscussionThere is widespread acceptance that the generalizability of quantitative trials of KT interventions would be significantly enhanced to other contexts, health professional groups, and clinical conditions through complementary process evaluations alongside trials. This systematic review will serve as a ‘state of the science’ on methodological approaches to process evaluations and will allow us to: 1) take stock of current research approaches and 2) develop concrete recommendations for knowledge users (e.g., quality consultants and health services researchers) designing future KT process evaluations.Electronic supplementary materialThe online version of this article (doi:10.1186/2046-4053-3-149) contains supplementary material, which is available to authorized users.

Planning and evaluating population interventions to reduce noncommunicable disease risk - reconciling complexity and scientific rigour?

Noncommunicable diseases (NCDs) are the leading global causes of morbidity and mortality. It is important to develop and deliver effective NCD prevention programs, but these have been difficult to evaluate. Technical approaches differ, with academic researchers, practitioners and policy makers each bringing different perspectives and priorities to the task of NCD program evaluation. Epidemiologically defined hierarchies of research evidence give preference to evaluation methods that are often unsuitable for assessing complex NCD prevention interventions. This may lead to interventions that provide the 'right answer to the wrong question', or to evaluation data that are insufficient to inform NCD prevention efforts. This paper recommends a set of standardised stages in the planning, development and evaluation of NCD prevention programs, including the use of logic models, the expanded use of process evaluation to better understand and record the context for implementation, and the use of appropriate research designs for assessing the impact of both subcomponents and the whole program. NCD prevention agencies and academic stakeholders need to recognise the limitations of established evaluation designs and support greater flexibility in the application of evaluation methods that are fit for purpose in describing the stages in NCD programs. This involves assessing policy development and implementation, measuring intermediate indicators, using mixed methods of evaluation, and employing population surveillance systems to assess long-term outcomes.

The Utilization of Process Evaluations in Childhood Obesity Intervention Research: A Review of Reviews

Process evaluations are an essential component to evaluating health promotion programs, however they are consistently under-utilized and oftentimes not reported upon in the literature. This study reports the use of process evaluations in childhood obesity prevention interventions implemented over the past three decades. Seven meta-analyses and systematic reviews were located for this review or reviews, and from these, 119 unique references were identified. Each article was retrieved and read for appropriateness, and 20 were excluded for a variety of reasons (ex. not published in English language), resulting in 99 articles included for this study. Overall, process evaluations were not well reported upon. Only 38 studies reported the fidelity of program implementation, 25 studies tracked participant attendance, 29 studied evaluated participant satisfaction, and 49 studies reported how staff members were trained. Additionally, one-third of the studies did not report using a single type of process evaluation, and only 5 studies reported using all four types. Results from this study suggest that the use of process evaluations has been low in this area of research, which may explain why many obesity prevention studies have reported mixed or modest results. Suggestions for implementing simple, yet effective process evaluations in future studies will be presented.

Process Evaluations for a Multisite Nutrition Education Program

Process evaluations are an often-overlooked component of evaluating health promotion interventions, but can be essential for interpreting program outcomes. The purpose of this study was to report the results of two types of process evaluations conducted for Food Fit, a nutrition education program implemented to 58 3rd through 5th grade children (67% Caucasian) in 5 YMCA after school programs. To evaluate program fidelity, a trained observer watched each lesson and recorded program adherence using a standardized checklist, outlining essential components of the intervention. Attendance was recorded by asking each child to complete a small task before and after each lesson. Results showed that program adherence was perfect in most cases and attendance rates varied, but were generally high. Attendance rates were not associated with improvement in nutrition behaviors. Implications and recommendations for future use of process evaluations are discussed.

The Ergonomic Program Implementation Continuum (EPIC): Integration of health and safety - A process evaluation in the healthcare sector

IntroductionThis article presents a health and safety intervention model and the use of process evaluation to assess a participatory ergonomic intervention. MethodThe effectiveness of the Ergonomic Program Implementation Continuum (EPIC) was assessed at six healthcare pilot sites in Ontario, Canada. The model provided a framework to demonstrate evaluation findings. ResultsParticipants reported that EPIC was thorough and identified improvements related to its use. Participants believed the program contributed to advancing an organizational culture of safety (COS). Main barriers to program uptake included resistance to change and need for adequate funding and resources. The dedication of organizational leaders and consultant coaches was identified as essential to the program's success. Impact on IndustryIn terms of impact on industry, findings contribute to the evidence-based knowledge of health and safety interventions and support use of the framework for creating a robust infrastructure to advance organizational COS and link staff safety and wellness with patient safety in healthcare.

After-School Based Obesity Prevention Interventions: A Comprehensive Review of the Literature

The purpose of this article was to review primary prevention interventions targeting childhood obesity implemented in the after school environment from 2006 and 2011. A total of 20 interventions were found from 25 studies. Children in the interventions ranged from kindergarten to middle schoolers, however a majority was in the 4th and 5th grades. Most of the interventions targeted both physical activity and dietary behaviors. Among those that focused on only one dimension, physical activity was targeted more than diet. The duration of the interventions greatly varied, but many were short-term or brief. Many interventions were also based on some behavioral theory, with social cognitive theory as the most widely used. Most of the interventions focused on short-term changes, and rarely did any perform a follow-up evaluation. A major limitation among after school interventions was an inadequate use of process evaluations. Overall, interventions resulted in modest changes in behaviors and behavioral antecedents, and results were mixed and generally unfavorable with regards to indicators of obesity. Recommendations for enhancing the effectiveness of after school based childhood obesity interventions are presented.

Prevention of bullying and conflicts at work

PurposeThis paper aims tp prevent bullying and conflicts at work and to identify process factors associated with the implementation and effects of such interventions.Design/methodology/approachThe paper presents process evaluation data from an intervention study in two organizations. A quasi‐experimental, process‐oriented research design was used. The following interventions were implemented: lectures on bullying, courses in conflict prevention and management, dialogue meetings, the distribution of pamphlets, newsletters and posters as well as steering group meetings.FindingsResults indicate that participants benefited from the interventions, in particular the dialogue meetings and the courses in conflict prevention and management. Moreover, various factors stimulating or obstructing the implementation and effects of interventions were identified.Research limitations/implicationsThe use of process evaluation to document the phases of the study and relevant process factors is a major strength. However, the study only included two public sector workplaces and no control groups.Originality/valueThe use of qualitative process‐evaluation helped identify important process factors affecting the implementation of interventions and their perceived effects. The paper thus yields valuable knowledge to researchers and practitioners.

The impact of day care on socially disadvantaged families: an example of the use of process evaluation within a randomized controlled trial

This paper describes a process evaluation that was conducted alongside a randomized controlled trial of out-of-home pre-school day care. The evaluation aimed to: (1) describe the intervention; (2) document the day care received by participating families; (3) describe the social context of the trial; and (4) provide data to assist in the interpretation of trial outcomes. The setting for the trial was an out-of-home day care Centre in Hackney, East London. Process data were collected through the use of questionnaires, interviews, and researcher field-notes. Data from questionnaires were collected from 120 mothers and included data on 143 children. Interviews were undertaken with 21 participating mothers. Staff also completed questionnaires and the Head of the Centre was interviewed. The quality of care provided was assessed using the Early Childhood Environment Rating Scale. Process data collected during the trial suggest that the day care provided was education-led, flexible in catering to families' needs, and was of a very high quality. The social context of the trial resulted in financial pressures, which may well have influenced the intervention provided. Data collected through in-depth interviews suggested that it may be the flexibility of day care that is particularly important in allowing women to return to paid employment, but that the loss of benefits when starting work may have meant no increase in household income. The paper illustrates the value of conducting a process evaluation alongside a randomized trial, particularly where complex interventions are involved. In this case, where the intervention was not provided by the research team, the evaluation allowed an insight into the content of a multifaceted intervention, which is useful in interpreting the trial's results, and in explaining the possible effects of the social context on the intervention.

The value of process evaluation in a community-based cancer control program

The Cancer Awareness Program was a four-year community health education project conducted in six rural North Carolina counties. The educational program was designed to increase breast, cervical, and skin cancer screening behaviors in low income women. Female clients of the health department in each county, aged 20 and older, were eligible for the program. Program intervention activities were targeted both to the health departments and to the individual women, in addition to the community. Intervention activities included media messages, telephone counseling of participants, community presentations, printed materials, bulletin boards, and direct education. Process evaluation allowed for regular monitoring of all program components, identifying any areas in need of modification, and was developed for the long distance supervision of the project as well. Measures consisted of videotaping of presentations, meetings with key individuals and staff, participant evaluations and feedback, focus groups, and weekly activity reports from staff. The results of the process evaluation enabled investigators to pinpoint effective intervention components that led to desired results. In addition, it allowed investigators to define areas in need of modification, and adjust specific components. Final evaluation of the project indicated that the intervention significantly increased participation in screening for skin cancer and breast cancer. Included in the paper are the purposes of each process method, problems identified, and their resolution. Suggestions are made for use of process evaluation in community health education programs.

Using process data to explain outcomes. An illustration from the Child and Adolescent Trial for Cardiovascular Health (CATCH).

The purpose of this article is to illustrate the use of process evaluation for understanding study outcomes. Data from the Child and Adolescent Trial for Cardiovascular Health (CATCH), a large school-based field trial, are used. Teacher characteristics, measures of classroom curriculum implementation, and competing influences are linked to changes in dietary knowledge, intentions, and self-efficacy of students in the intervention schools. Multiple regression analyses indicate that teacher characteristics did not predict program implementation. Teacher characteristics and program fidelity, or the number of modifications made to the classroom curriculum during implementation, had direct and independent effects on student outcomes.