Howell 2005.

Methods	Included as outcome evaluation and process evaluation Study design: clustered parallel‐group design with schools selected as the unit of randomisation Setting: 4 elementary schools in Syracuse City, New York, USA Period: conducted December 2003 to January 2004; subsequent data collected through September 2004 Process evaluation methods: descriptive/bivariate
Participants	Eligible sample frame: 40 families found to be eligible and 30 consented, with 5 others unable to participate before randomisation Randomised: 25 families (children and caregiver), with 16 selected into the intervention group and 9 into the control group Completed (intervention): no reports of permanent attrition Inclusion criteria: target child was between 8 and 11 years of age and was in third to fifth grade with a diagnosis of asthma and prescribed daily medications for asthma as reported by nurse and/or parent Exclusion criteria: coexisting chronic illness that required daily medication (e.g. insulin‐dependent diabetes) Baseline characteristics Age of children: mean age, 9 years 7 months; range, 8 to 11 years Ethnicity: 75% of children were African American Socio‐economic status: unclear Gender: 63% male Asthma status: all children had a record of asthma, although study authors did not describe asthma severity
Interventions	School type: primary/elementary Intervention description: children in the intervention condition received four 30‐minute sessions on the "Quest for the Code" computer game at their school. The computer game included modules on Lung Physiology; Symptom Recognition; Trigger Recognition; Peak Flow Meter Usage; Appropriate Use of Long‐Term and Reliever Medication; Correct Usage of Common Asthma Medication; and Effect of Asthma Medications on Lungs. The child's primary caregiver participated in a medication routine interview in the home and received a 1‐time home visit at which a medication routine plan was developed Control description: usual care/no additional intervention Theoretical framework: learning theory principles and behaviour modification
Outcomes	Core processes evaluated (child level): attrition, dosage, adherence
Notes	Process evaluation category: named section Breadth and depth: neither broad nor deep Voice of children given prominence: the voice of children was featured but not sufficiently Funding source: not reported
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Information not given: this study was a pretest, intervention, post‐test, follow‐up (PPF) RCT with random assignment based on school site
Allocation concealment (selection bias)	High risk	Information not given; few students were randomised and concealment may have been breached
Blinding of participants and personnel (performance bias) All outcomes	Unclear risk	Not addressed in the study
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Not addressed in the study
Incomplete outcome data (attrition bias) All outcomes	Low risk	Low risk ‐ low levels of attrition are reported in the study
Selective reporting (reporting bias)	Low risk	No evidence of selective reporting
Other bias	High risk	Missingness ‐ high risk ‐ small sample and evidence of missingness for some indicators Baseline imbalance ‐ high risk ‐ described in the introduction as imbalanced Risk of contamination ‐ low ‐ randomisation occurred at a school level
Transparent and clearly stated aims	Low risk	Study aims were clearly stated
Explicit theories underpinning and/or literature review	Low risk	Intervention was informed by learning theory principles and behaviour modification
Transparent and clearly stated methods and tools	Low risk	Study included a broad‐ranging description of tools implemented at different time points
Selective reporting	Unclear risk	Some statements from parents are impenetrable; other statements describe kids enjoying the intervention but are not entirely clear on how this feedback was obtained
Harmful effects	Unclear risk	Study methods do not highlight the possibility of negative effects
Population and sample described well	Unclear risk	Only basic demographic information was included
Continuous evaluation	Low risk	Not continuous; however 3 time points were considered
Evaluation participation equity and sampling	Unclear risk	Information was collected from parents and children only
Design and methods overall approach	Low risk	This was an RCT but with dedicated attention to feasibility
Tools and methods of data collection reliable/credible	Low risk	Validated measures were used
Tools and methods of data analysis reliable/credible	Unclear risk	Small study sample precludes usefulness of confounding data
Performance bias/neutrality/credibility/conformability	Unclear risk	Process was limited
Reliability of findings and recommendations	Low risk	How the data relate to study findings is clear
Transferability of findings	Unclear risk	Study sample was too small, so transferability is limited
Overall risk of bias of process evaluation	Unclear risk	Small sample compromises much of the information provided in this study