Table 2.

Modifications to the GOALS delivery mechanisms during the study period and lessons learned

TIDieR item	Modification	Rationale and lessons learned
What—procedure (4)	During year 1 every child was assessed for underlying causes of obesity and comorbidities by a community paediatrician. In year 2, this was replaced with an assessment with a school nurse and later a self-completion form by the parent/carer with recommendations to visit the family GP before starting the intervention.	The available guidelines for treating childhood obesity recommended all children with a BMI ≥99.6th centile be referred to hospital or community paediatric consultants before treatment was considered50 and a medical assessment be undertaken of presenting symptoms and underlying causes of overweight and obesity, comorbidities and risk factors, and growth and pubertal status.51 As the majority of children registering for GOALS had a BMI ≥99.6th centile, assessment by community paediatricians proved a time-consuming and costly arrangement, and research suggested these assessments may not be necessary for all obese children.52 The protocol was therefore replaced by an assessment with a school health practitioner and later a self-completion form by the parent/carer, in which they were signposted to the GP.
Where (7)	Year 1 interventions were delivered in primary (n=4) and secondary schools (n=3). Year 2 and 3 interventions were delivered in secondary schools only.	Owing to the multidisciplinary nature of the intervention, each site required space for PA, facilities for cooking and classrooms for general activities. Primary schools were rarely open during evening hours (and thus incurred costs for site management) and cooking facilities were often limited to the school kitchens. By contrast, secondary schools provided ideal space for group cooking sessions in food technology rooms and were often open during the evening for adult education classes (thus allowing free access).
Who provided (5)	During year 1, Fun Foods was led by community dietitians (theory-based sessions) and community food workers (practical sessions) employed by the NHS in Liverpool. From year 2, the employment of all Fun Foods staff was transferred to Liverpool John Moores University. A public health nutritionist delivered the theory-based sessions and food workers continued to deliver practical elements. In September 2008 (mid-year 3) all food workers were trained to be ‘nutrition mentors’, responsible for the delivery of both theory-based and practical sessions with ongoing training and supervision from the public health nutritionist.	Little guidance was available outlining the skills required for delivery of healthy eating sessions in the community. Since the intervention focused on general healthy eating advice rather than individually-prescribed diets, it was established that a public health nutritionist possessed the relevant skills for supervision and quality assurance of the Fun Foods element of the intervention.
Who provided (5)	A qualified counsellor began working with GOALS in February 2007 (end of year 1) to provide additional support for children and families where appropriate.	The group session provided little opportunity for children or families to discuss personal issues that may have been affecting their lifestyle change (eg, if children were being bullied). The GOALS lifestyles counsellor provided an impartial source of support for children or families who needed to talk something through that went beyond the remit of the GOALS staff. Several different ways of working were explored, ranging from informal drop-ins during the weekly session, group sessions about feelings, and fixed appointment times for families either during or outside of the weekly session. While the support was deemed beneficial for families, it proved difficult to sustain financially and the counsellor's involvement ceased a short time after the study period.
Tailoring (9)	During years 1 and 2, a mobile crèche was provided on site for younger siblings (if required). During year 3, younger siblings were included in the main programme.	To allow whole families to attend, it was important provision was made for the childcare of younger siblings. Therefore a free créche was provided for families at the intervention site. However the mobile créche proved costly given the small number of children who used it, and children often expressed a wish to join in the main group's activities. The option of arranging local child-minders was explored but the families concerned were reluctant to leave their children with an unknown adult. Therefore the most appropriate solution was to accommodate young children within the main session, with an allocated staff member to take them aside for age-appropriate activities where necessary.
Tailoring (9)	The number of interventions in which taxis were provided for families increased with each year (1/7 in year 1; 3/7 in year 2; 4/7 in year 3).	As it was not possible to provide intervention sites in every district of the city, consideration was given to the provision of transport for families who lived further afield. Several options were explored, including reimbursement of public transport expenses for families without a car and arrangement of taxis to and from sessions. It was however a challenge to develop objective criteria for offering these services and there was some concern the arrangement of taxis hindered the lifestyle change process for families. Financial support for transport was ceased after the study period, and staff instead supported families to identify appropriate public transport solutions.
When and how much (8)	A family-based weekly PA session for ‘GOALS graduates’ was piloted between May 2007 (start of year 2) and July 2008 (mid-year 3).	Families expressed a wish for continued support beyond the 18-week intervention. However, sessions later ceased due to poor attendance and pressure to allocate financial resources to the main intervention.

Numbers in parentheses in the first column refer to the item number on the TIDieR checklist.³⁹

Year 1=September 2006–March 2007; year 2=April 2007–March 2008; year 3=April 2008–March 2009.

BMI, body mass index; GOALS, Getting Our Active Lifestyles Started; GP, general practitioner; TIDieR, Template for Intervention Description and Replication.