Implementing Smarter Lunchrooms Makeovers in New York state middle schools: an initial process evaluation.

BACKGROUND
This paper presents design and findings from the process evaluation of a randomized controlled trial (RCT) testing the effectiveness of Smarter Lunchrooms Movement (SLM) interventions to encourage consumption of either fruit, vegetables, or unflavored milk in middle school cafeterias (grades 6-8, typically children ages 10-14 years). Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework adapted for environmental interventions, the process evaluation monitored fidelity to SLM protocol, determined barriers and facilitators influencing fidelity, and identified the training and support needs of implementers.

METHODS
Under research team guidance, community partners (interventionists) assisted school food service staff (providers) with a six week implementation of protocol items in 13 public middle school cafeterias (two milk treatment, three vegetable treatment, four fruit treatment, and four control) in New York State during the 2013-2014 academic year. Process evaluation measures included semi-quantitative measures of implementation and maintenance (lunchroom audits) and qualitative data (environmental assessments and semi-structured interviews with school food service staff). Analyses identified challenges and opportunities for improving intervention delivery.

RESULTS
Approximately 75 % of enrolled students participated in school lunch programs and thus were exposed to the SLM intervention. Findings indicated potential contamination by other nutrition-related activities in the lunchroom and larger school environment may have affected the intervention impact. Modest implementation fidelity scores were observed for intervention treatments. Providers reported treatments were acceptable and feasible, however interventionists confirmed motivation and perceived effectiveness varied among schools. Post-intervention audits revealed limited maintenance of intervention protocols. Strategies to enhance buy-in and communication among providers and increased interventionist support are recommended.

CONCLUSIONS
RE-AIM was a valuable framework for this process evaluation. Results highlighted implementation barriers and facilitators, and findings will enhance interpretation of forthcoming outcome data. Results will inform future iterations of the SLM RCT and provide valuable insights for those designing environmental interventions in school cafeterias.