2.1.1. Task 1 – Analyzing health and quality of life problems and their causes

2.1.2. Task 2 – Program goals

In the IM framework, program goals are defined as the changes to be made regarding the health, quality-of-life, behavioral, or environmental factors identified in the needs assessment (Bartholomew-Eldredge, 2016). Based on our needs assessment, we decided that our intervention should mainly address dietary patterns during adolescence because diet quality influences risk regardless of energy balance (Mozaffarian, 2016). The overall program goals are as follows: (1) improving dietary adherence to nutritional guidelines; (2) increasing the level of dietary knowledge; and (3) preventing the development of obesity during adolescence. Any materials developed should be culturally appropriate, easy to use by Lebanese dietitians, and easy to understand by Lebanese students, and capable of being incorporated later in the school curriculum.

It is worth noting that the program focuses on adolescents and does not include parents for two reasons: (1) adolescents are capable of preparing their own food and applying the advice mentioned in this program, in contrast to younger children; (2) based on a pilot study (Said et al., 2019), the participation rates of parents filling in questionnaires were low, and therefore it was not promising to include parents in an intervention.

As a first step, only individual determinants were taken into consideration because a previous study (Said et al., 2019), conducted on a smaller similar sample, indicated that it would be wise to focus first on high schools, to prevent making the intervention too disruptive for other settings at the same time. According to (Bartholomew-Eldredge, 2016), it might be difficult to modify an environmental condition in some situations. In that case, the program planners can prepare the at-risk population to deal with the environmental condition instead of planning an intervention for an environmental outcome. For instance, due to limited financial resources and space at schools, school shops are not able to offer healthy snacks to the students. In this case, it is possible to teach the students how to prepare their own snacks at home and bring them to school. The current intervention did not directly involve the parents, the schools, nor other environmental factors. Such an approach was previously used in Kaledo intervention (Viggiano et al., 2015).

2.2.1. Task 1 – Behavioral outcomes

Behavioral outcomes are behaviors to be accomplished as a result of the health promotion program (Bartholomew-Eldredge, 2016). They can additionally be considered the final or distal objectives (Fassier et al., 2016). In this study, behavioral outcomes were divided into two categories: (a) health-promoting behaviors representing actions taken to protect or enhance health; (b) risk-reduction behaviors defined as actions that have been demonstrated to directly decrease the risk of disease or disability (Bartholomew-Eldredge, 2016).

All outcomes (see Box 1) target Lebanese adolescents participating in the intervention group and are expected to be achieved by the end of the intervention. They are based on the recommendations listed in the consensus statement from the American Heart Association (Gidding et al., 2005) and the Dietary Reference Intakes (Institute of Medicine, 2005), and they are obtained as a result of the needs assessment (Step 1). Although this intervention focused on dietary behaviors, the educational material included one chapter related to PA for the following reasons: (1) the influence of PA levels on food intake; (2) clustered behaviors or the co-occurrence of healthy behaviors with other healthy ones (e.g., exercising and following a healthy diet), and vice versa (Kremers et al., 2006). It is important to note that while two behavioral outcomes regarding physical activity and screen time were included in addition to the nutrition-related behavioral outcomes (Box 1), we will further address the recommendations and focus as “dietary” for the purpose of clarity of the paper.

As achieving some dietary recommendations may not be a realistic goal for many individuals, it was decided that the objective of the intervention would be to “increase” or “decrease” the intake of certain food products with a view to achieving the recommended levels.

2.2.2. Task 2 – Performance objectives

The second task of the second step is to specify performance objectives (POs) for each behavioral outcome. POs represent a step-by-step checklist of what needs to be done in order to reach the outcome (Bartholomew-Eldredge, 2016). To select the POs, we conducted an extensive literature review and a pilot study on a similar sample to make sure that the listed POs are feasible, possible to reach within the current school settings and resources, culturally appropriate, and accepted by the adolescents (Said et al., 2019). They can be found in Table S1-A (Supplementary file 1).

2.2.3. Task 3 – Determinants

The third task of the second step is to select determinants of the stated POs for the health-promoting and risk-reducing behaviors (Bartholomew et al., 1998). First, following the Core Processes methodology, a brainstorming session was conducted to identify determinants correlated with the eating behavior of children and adolescents. Next, we reviewed the empirical evidence linking the factors to the behavior and the evidence that once the determinants change, the behavior condition will also change (Bartholomew-Eldredge, 2016). Each determinant was assigned a score (Stok et al., 2018; Stok et al., 2017). The ranking procedure was adapted from Bartholomew-Eldredge (2016) as + meaning not very important/not very easy to change; ++ meaning important/changeable; +++ meaning very important. Finally, the determinants with the highest modifiability and relevance scores were selected (knowledge, self-efficacy, attitude/positive emotions, and self-regulatory skills). The importance and modifiability scores of each of the determinants can be found in supplementary file 1 (Table S1-B).

After identifying the determinants of each behavioral outcome, we linked them to relevant POs using the literature review gathered from the needs assessment.

2.2.4. Task 4 – Change objectives

After writing the POs for each behavioral outcome and specifying the corresponding determinants, the final task in Step 2 is to assess each cell of the matrix and judge whether the determinant is likely to influence accomplishment of the PO (Bartholomew-Eldredge, 2016). A selection of determinants was made to maintain a feasible length for the total program. Next, the planner writes change objectives (COs) for the personal determinants (Bartholomew-Eldredge, 2016). COs describe what needs to change, related to the determinants, for the person to execute the POs (Bartholomew-Eldredge, 2016). Table 1 presents an example of a behavioral outcome, POs, COs, and their corresponding determinants (the complete matrix is listed in Table S1-A – Supplementary file 1).

2.3.1. Task 1 – Generating ideas for program themes, components, scope, and sequence with the planning group

First, the planning group (a dietitian and health promotion experts) evaluated both the potential program participants (represented by Lebanese adolescents in our case) and implementers to achieve a good overall balance between the applications, the program itself, change methods, and the program context (Bartholomew-Eldredge, 2016) based on the needs assessment obtained in Step 1. According to IM principles, the intervention plan must also account for the scope and sequence of the program, a description of each population group and program interface, and a list of program materials and staff required for the interface (Bartholomew-Eldredge, 2016). At this stage, the implementation is small scaled with only one dietitian implementing the intervention. This approach will be evaluated and used as an input for implementation on a larger scale.

In our intervention, the program participants are Lebanese adolescents aged 15–18 years who are registered in public and private high schools. The implementer of the program is a dietitian who delivers the intervention directly to the students in classroom settings at the participating schools. Each school principal designates one or two sessions per week based on the available courses, exam schedule, and holidays. The length of the intervention is expected to be around 7–10 sessions, until all topics are covered (scope). Each session lasts 20–40 minutes. The interventional material should include different chapters or lessons. Each chapter is supposed to tackle a different topic about nutrition and PA (sequence).

The program theme is encouraging healthy eating habits and regular PA practice. The program is entitled Sahtak bi Sahnak (in Arabic صحتك بصحنك), which can be translated as ‘your health on your plate’. The title is short, easy to remember, and reflects the purpose of the intervention which is to improve the quality of life and overall health by adopting healthy eating habits.

Three communication channels are included in this intervention: interpersonal, circulating print, and display print. Four vehicles were selected: health care provider (registered dietitian), intervention booklet or manual, brochures distributed to the participants at the schools, and posters displayed at schools. Having a registered dietitian with professional experience in dealing with the pediatric population to deliver the Sahtak bi Sahnak intervention has many advantages. First, an expert in nutrition represents a powerful source of influence and persuasion (Bartholomew-Eldredge, 2016). This also captivates audiences interested in personal health issues, increases the ability to integrate evidence-based messages, and involves individuals with expertise in patient assessment and counselling (Bartholomew-Eldredge, 2016). Advantages related to using a booklet include: good audience segmentation, high audience receptivity, strong possibility for tailoring, control of distribution, and multiple messages with ongoing reach (Bartholomew-Eldredge, 2016). In other words, using booklets not only ensures that the information reaches the target population, it also allows for separating participants into two groups (intervention and control; see step 6) later in the evaluation step, and avoiding some bias such as contamination of information by controlling adolescents who receive the booklet. Posters can be very effective vehicles because they include direct messages and can be tailored to an audience by using novel images and language (Bartholomew-Eldredge, 2016). However, they have a limited influence on learning and change objectives (Bartholomew-Eldredge, 2016), so they were combined with other vehicles. As for brochures, they present many advantages as well. They can affect a variety of learning and change objectives (unlike posters). They are useful as part of multi-strategy messages, complementing other vehicles. They are also used for community-based learning, which is suitable in our case, and they reinforce the messages and the delivery of key messages (Bartholomew-Eldredge, 2016). These vehicles were chosen to suit all schools, which have different resources. For instance, PowerPoint presentations were not used because not all classes were equipped with LCD projectors.

2.3.2. Task 2 – Choosing theory and evidence-based change methods to address program objectives

Theory and evidence-based methods are general techniques for influencing modifications in determinants of behaviors of the at-risk group or environmental agents. To match a method with a change objective, the linking concept is the determinant involved (Bartholomew-Eldredge, 2016).

Methods were selected to match the indicated determinants, taking into account the suitability for application in a Lebanese school-setting with limited human and financial resources. For instance, active learning strengthens the two-way communication and improves the meaningful application of knowledge (Gleason et al., 2011). Verbal persuasion helps to mobilize more efforts to achieve certain behaviors and sustaining them (Bandura, 1998). In addition, guided practice is used to initiate a behavior and improve consistency (Jackson, 1997). Feedback helps in maintaining self-efficacy by solving identified problems and adjusting unhealthy behaviors (Glanz, Rimer, & Viswanath, 2008). As for self-reevaluation, it helps in progressing towards the initiation of a behavior and its’ assessment and/or alteration (Glanz & Schwartz, 2008). Counterconditioning and stimulus control help in substituting old behaviors with new ones (Bouton, 2000; J. Prochaska, Redding, & Evers, 2008). Therefore, adolescents associate a signal (e.g., hunger) with a healthy event (e.g., healthy food choices) instead of unhealthy behaviors (e.g., unhealthy food choices).

Several theories were applied to target the previously selected determinants (knowledge, self-efficacy, and skills): the Social Cognitive Theory (Bandura, 1999, 2004), the Transtheoretical Model or Stages of Change (J. Prochaska et al., 2008; J. O. Prochaska, DiClemente, & Norcross, 1992), Theories of Information Processing, Theory of self-regulation, Elaboration Likelihood model, and theories of learning. An example of some change methods selected for certain COs, based on these theories, is presented in Table 2 (see Table S1-C – Supplementary file 1 for the complete table).

2.3.3. Task 3 – Selecting or designing practical applications to operationalize change methods

As part of the third task of step 3, the educational booklet of Sahtak bi Sahnak focuses on the outcomes listed in Box 1. Each chapter deals with one aspect of the nutritional guidelines such as the importance of fiber, water intake, etc. It also includes practical activities and trackers, enabling application of the knowledge gained and following their progress. Each session starts with a discussion between the dietitian and the adolescents. The participants are asked what they already know about the selected topic. Then the educator explains the lesson and uses familiar examples from daily life and practice to explain complex information (e.g., atherosclerosis and osteoporosis). It is important to note that the participants are not supposed to passively receive the information, but rather to participate in the discussions, give their opinion, and compare their own behavior with the recommendations. At the end of the intervention, the adolescents should be able to plan their own meals, self-evaluate their intake, and recognize the available opportunities and barriers affecting their eating habits.

2.4.1. Task 1 – Refining the program structure and organization that were generated in the preceding step

In the first task of step 4, the planners prepare what the participants will see, read, do, etc. as part of the intervention (Bartholomew-Eldredge, 2016). Additionally, it is important to indicate where the potential participants are going to interact with the program, and how to ensure that they will be in contact with what was planned (Bartholomew-Eldredge, 2016).

The school setting was selected for several reasons: (1) to reach as many adolescents as possible; and (2) many school-based interventions showed positive outcomes when it comes to improving dietary knowledge, healthy eating habits, PA practice, and adiposity (Ardic & Erdogan, 2017; Maatoug et al., 2015). Additionally, school-based nutrition education and promotion can improve the students’ academic performance (Briggs, Fleischhacker, & Mueller, 2010). In Lebanon, 129,428 students are enrolled in public and private high schools, and 84.4% of all students are Lebanese (Center for Educational Research and Development, 2018).

When planning school-based interventions, the planners must determine how much material can be delivered and cognitively processed in one class session, and how many class hours are needed and can be realistically devoted to the program (Bartholomew-Eldredge, 2016). In the Sahtak bi Sahnak program, after receiving the agreement of the school principal, we scheduled 20- to 40-minute sessions once or twice a week to deliver the intervention, depending on the exam dates and holidays.

It is important to note that the feasibility of delivering materials was already taken into consideration during the third step of IM. Therefore, no notable changes in the program structure and organization had to be made at this stage.

2.4.2. Task 2 – Preparing production plans

Production plans or design documents guide production to ensure that the program materials and activities are culturally relevant, meet the intervention’s objectives, and follow the parameters for use of their selected COs and practical objectives (Bartholomew-Eldredge, 2016). The lessons were titled as follows: benefits of healthy eating, principles of healthy eating, lipids, physical activity, healthy weight, challenges of healthy eating and physical activity practice, vitamins and minerals, importance of water, nutritional facts label, diets, and food safety. It is important to note that the last chapter related to food safety was added to increase awareness about another nutrition-related topic leading to healthy eating, as healthy food should also be safe to eat. Table S1-E (see Supplementary file 1) lists all the chapters and activities conducted during the educational sessions.

The dietitian provided the educational sessions to each class in accordance with the schedule proposed by the school until all of the chapters had been covered. The program was age appropriate and written in an understandable language. The material was designed by a Lebanese registered dietitian (PI), taking cultural relevance into account. It was written and delivered in Arabic. The program was carefully designed to suit all Lebanese adolescents. For instance, some food items like alcohol were not part of the material as it is religiously considered a forbidden food by Muslims, who form a large part of the target population. Participants received a booklet of all the educational sessions.

2.4.3. Task 3 – Drafting messages and producing preliminary materials and protocols for the health promotion program

In the third task of step 4, all messages were written, translated, and finalized. First, the text of the educational material was originally written and delivered in Arabic (native language of the participants) to avoid language bias. Then, the material was translated into English, and back translated, to ensure that there is an English copy of the material to be consulted by other researchers or health promoters planning health interventions in the future.

Second, all scientific and medical terms were simplified and explained. Clear visuals that were immediately understood were used. No complex figures nor distracting backgrounds were employed. The pictures were more realistic than symbolic. And most importantly, long paragraphs were avoided, and bullet points were used to reduce the text.

Third, the booklets were printed and distributed to participants. They included 11 chapters and many fun activities (see Supplementary file 1 – Table S1-E). We purposefully used physical or hardcopies to make sure that each student would have his/her own material available during the lessons, and to avoid the need of printing the booklet at home and thus additional costs.

Fourth, the material was reviewed by a health expert in health promotion before finalizing it. In addition to the booklet, a poster was displayed on the walls of the classrooms, listing the essential recommendations regarding healthy eating and PA.

The educational material focuses more on healthy eating habits rather than obesity to avoid possible negative perceptions such as an idealization of thinness leading to an eating disorder (Polivy & Herman, 2002). As we are including all of the students in the classrooms as participants, this reduces social stigmatization (Ten Hoor et al., 2016) and prevents the situation that children who are not overweight or obese would not be interested in participating in the program. This situation was seen with the parents of some students in a previous pilot study (Habib-Mourad et al., 2014). Moreover, 3.9% of Lebanese children under the age of 5 years are underweight (Musaiger et al., 2011).

2.5.1. Task 1 – Identify program adopters, implementers, and maintainers

Before making a decision on the implementation, the planners must be informed about certain characteristics of the organization in which the intervention will be implemented, such as the size, leadership, general capacity, and feasibility of implementation (Bartholomew-Eldredge, 2016). In the present intervention, the program adopters are the school principals, as they decide whether or not to participate in an intervention. It is worth noting that public schools are not allowed to participate in any program without the approval of the Lebanese Ministry of Education. This is not the case for private schools.

The implementer of Sahtak bi Sahnak is the PI. Having only one implementer decreases the risk of information delivery disparities. This method of information delivery was previously mentioned in other reviews and studies (Habib-Mourad et al., 2014; Van Cauwenberghe et al., 2010). The program did not rely on teachers to deliver the intervention for several reasons: (1) this would require teachers spending additional time to be trained (e.g., staying after school), which is quite challenging; (2) they would need to teach supplementary lessons, requiring additional effort that not all of them were willing to make, and more work without additional pay; (3) the material is not part of the official curriculum, therefore, they will not be motivated to teach it as the students might not take it seriously.

As for the future maintenance of the program, we recommend including the present intervention as part of the school curriculum (e.g., life sciences course), after training the teachers on how to deliver it as part of their continuing education plan. This will reduce the costs of hiring external staff. Teachers will be trained by the PI to deliver the information following the specified methods in table S1-C. Teachers may also use the dietary knowledge and adherence questionnaires to assess the dietary knowledge and adherence levels before and after the intervention. The training will include: (1) an explanation of the methods that should be applied; (2) the time that should be dedicated for each lesson; and (3) an explanation of the educational material. Teachers may follow the same POs as in Table 4.

2.5.2. Task 2 – Stating outcomes and performance objectives for program adoption and implementation

During the second task of the fifth step, we need to determine who has to do what in order for the program to be adopted, implemented, and maintained with acceptable completeness and fidelity (Bartholomew-Eldredge, 2016). The main adoption outcome was that at least 10 high school principals would adopt the Sahtak bi Sahnak program in the 2017–2018 academic year in their schools located in Beirut, Baalbeck, and Rayak (to reach a sample size of at least 800 participants). In this case, the POs are that the school principals: (1) evaluate the need to implement the program; (2) review all the information regarding the program; (3) sign the consent letter after deciding to participate in the program (see Table 3). The school management is an essential stakeholder for this intervention (Ten Hoor et al., 2016). Their commitment and involvement are important for the communication with the students and their parents. After the agreement, the school principals schedule the intervention sessions during class-time and visit all classes to introduce the program adopter (PI) and the program to the students.

As for the implementation, the main outcome is that the Sahtak bi Sahnak program is implemented the 2017–2018 academic year in the schools located in Beirut, Baalbeck, and Rayak. POs are the following:

PO1- The PI prepares the educational material for the Sahtak bi Sahnak program;

PO2- The PI implements all the lessons;

PO3- The PI provides the educational material to all participants (see Table 4).

In addition, the PI should provide program updates to the research team. At this stage, the planners clearly describe the implementation outcomes when defining POs for program delivery, considering such elements as fidelity, completeness, and dose (Bartholomew-Eldredge, 2016). The implementer is well aware of the duration needed to cover the required educational material and follow the plan, in addition to the amount of information to deliver in each session to avoid overloading participants with new instructions.

The last part of this task is related to program maintenance, when the program continues over time and becomes institutionalized (i.e., integrated as part of the organization’s routines) (Bartholomew-Eldredge, 2016). As maintenance is beyond the scope of the current project, we limit this part to mentioning who will maintain the program and the reasons behind doing so. Thus, before thinking about how this program can be maintained, we must consider the threats and facilitators of maintenance.

The main suggestion to maintain this program in the long term is to make it part of the school curriculum, instead of keeping it as a separate intervention, for several reasons: (1) avoiding the need to take other classes’ time: when this intervention was given during class-time, it was scheduled during other school classes such as physical education, second foreign language, or arts classes; (2) forcing all students to study the material: some students do not take extracurricular courses seriously because they are not included in the official exams. Another challenge to take into consideration is who will be taught to explain the lessons. Taking into consideration the limited financial resources in most of the schools, it would be better to train the teachers to deliver the intervention, as was practiced in many school-based interventions (Van Cauwenberghe et al., 2010). The lessons can be easily translated into English or French (an English copy is already available, and the French booklet is available upon request). However, it is important to note that the same outcome and POs will be followed during maintenance by school teachers, except for PO1 related to the preparation of the educational material as it has already been created.

2.5.3. Task 3 – Constructing matrices of change objectives for program adoption, implementation, and maintenance

During the third task of the fifth step of IM, we need to develop a matrix to guide the implementation and adoption (Bartholomew-Eldredge, 2016). We start by listing the determinants and COs related to adoption, and then move to implementation. Many factors affect the adoption of nutrition and PA related programs in Lebanese schools:

1. approval of the Lebanese Ministry of Education and Higher Education (MEHE): Lebanese public schools are not allowed to participate in any program without the approval of MEHE first. However, this is not the case for the private schools, which is why they are harder to recruit as each private school needs to be recruited separately (Habib-Mourad & Ghandour, 2015);
2. resources: Due to the school’s limited resources, the program should not create additional costs (Bergström et al., 2015).
3. knowledge: Principals agreed that obesity is an issue among school adolescents in general (Nollen et al., 2007). However, many reported that these cases were exceptions rather than the common rule (Nollen et al., 2007). In addition, they also agreed that schools may influence this problem and should be part of the solution (Nollen et al., 2007). However, recognizing the problem is not enough, the school principals should be aware of the health problems and consequences that obesity has on adolescents’ lives;
4. school priorities: Even though the school principals felt that student health was important, most of them did not consider it a top priority like academic achievement (Nollen et al., 2007). It is important to emphasize the correlation between healthy eating and PA and improved academic performance to increase the chances of adoption;
5. attitude: Some school principals showed a positive attitude towards PA (van den Berg et al., 2017). They reported that they found it important for their students as it positively influences the children’s ability to learn (van den Berg et al., 2017);
6. educational policy: School principals and school staff reported a lack of coverage of nutrition in the national curriculum (Townsend et al., 2017). They also added that the curriculum did not demand it because teachers lack the necessary knowledge and skills on this topic to teach them appropriately (Townsend et al., 2017). In addition, the educational policy places more importance in the school curriculum on subjects such as science and mathematics rather than agriculture (Townsend et al., 2017). It is another reason to encourage adopters to participate in this intervention as it fills this gap by having a nutrition expert teaching the students these missing chapters in their schoolbooks.

As for the implementation, the main determinants are (Atkins et al., 2017): (a) knowledge: being aware and familiar with the content of the material, objectives, and how to implement it; (b) attitude; (c) skills: being trained, having skills, and having practiced the implementation of the health promotion intervention in school settings for Lebanese adolescents; (d) self-efficacy: having confidence in implementing the program even when the participants are not motivated.

In addition to these determinants, many factors should be taken into consideration when implementing the intervention:

1. flexibility and work routines: Due to the high workload of schools, the program needs to be flexible and not to interfere with the school curriculum and exam schedule (Bergström et al., 2015);
2. meaningful content: the program should be perceived as meaningful and dealing with important issues (Bergström et al., 2015);
3. being part of a research project is considered a facilitator (Bergström et al., 2015). Apparently, people tend to trust such programs more since they are well controlled and supervised;
4. professionalism and personal contact with the research team (Bergström et al., 2015);
5. work routines: The classroom component was well accepted because it was well adapted to the school setting and easy to integrate into daily routines (Bergström et al., 2015).

Other determinants related to the implementation of the program include (Bessems, van Assema, de Vries, & Paulussen, 2014): (a) self-efficacy; (b) modelling; (c) outcome expectations; (d) low program complexity and compatibility with the subject that the implementer teaches; (e) perceived need for innovation: how relevant is the proposed innovation to the public’s needs? (Durlak & DuPre, 2008).

2.5.4. Task 4 – Choosing change methods and practical applications, designing the scope and sequence, and producing materials for an implementation intervention to influence program use

During the fourth task of the fifth step, the planners use information from the previous steps to select implementation methods and practical applications (Bartholomew-Eldredge, 2016). In this section, we only elaborated PO2 and PO3 because as the implementer is an experienced dietitian, there is no need for any training related to PO1. The related methods were matched to COs based on Bartholomew-Eldredge (2016). Table S1-F (see Supplementary file 1) provides detailed information of the behavior change techniques and practical applications used during this step (Hurley et al., 2016). The current evaluation study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Lebanese Ministry of Education (15465/3/2016; date: 06/10/2017) and the Lebanese International University Institutional Review Board (LIUIRB-171212-LS1) after reviewing all the educational material, questionnaires, and procedures.

2.6.1. Task 1 – Writing process and effectiveness questions coming from a review of the program logic models, goals, objectives, and the IM matrices

2.6.2. Task 2 – Developing indicators and measures to assess the selected effect and process evaluation questions

2.6.3. Task 3 – Specifying designs for conducting process and effect evaluations

The program planners used a clustered randomized controlled trial (CRT) to assess the efficacy of the Sahtak bi Sahtak program to improve the level of dietary knowledge of Lebanese adolescents, and to increase their adherence to nutrition recommendations to improve their overall health. Both qualitative and quantitative methods were used, therefore we followed the sequential mixed method design (Bartholomew-Eldredge, 2016). In this case, qualitative findings were used to explain the underlying reasons behind the quantitative results (Wisdom & Creswell, 2013).

2.6.4. Task 4 – Specifying and completing the evaluation plan

The results of the evaluation plan have been developed and published elsewhere.