Habib‐Mourad 2014.

Study characteristics
Methods	Study name: Health‐E‐PALS Study design: cluster‐RCT Intervention period: 12 weeks Follow‐up period (post‐intervention): nil Differences in baseline characteristics: reported Reliable outcomes: reported Protection against contamination: NR Unit of allocation: school Unit of analysis: individual accounting for cluster
Participants	N (control baseline) = 181 N (control follow‐up) = 175 N (intervention baseline) = 193 N (intervention follow‐up) = 188 Setting (and number by study group): 4 private and 4 public schools (2 each in each group) Recruitment: schools were purposively selected to include socioeconomically and religiously diverse catchment areas. Geographic region: Beirut, Lebanon Percentage of eligible population enrolled: all students in Grades 4 and 5 (aged 9–11 years) were invited to take part Mean age: intervention: 10.3 ± 0.9; control: 10.1 ± 1.0 Sex: intervention: 43% female; control: 57% female
Interventions	To evaluate a pilot multi‐component school intervention that is culturally appropriate to promote healthy eating and PA among children aged 9–11 years. The intervention specifically targeted obesity‐related behaviours in 9–11 year olds including: increasing consumption of fruits and vegetables, favouring healthy over high‐energy‐dense snacks and drinks, increasing the habit of having breakfast daily, increasing MVPA, and decreasing overall sedentary behaviour. 45‐minute classroom sessions were delivered each week for 12 weeks. Classroom sessions were delivered mainly by the 1st study author, a specialist in community nutrition, with the support of 1 research assistant who is also a nutritionist. Several co‐ordinated components as follows: 12 culturally appropriate classroom sessions using fun and interactive activities were delivered once a week for 3 consecutive months. The activities were incorporated into the school curriculum. At the end of the intervention, the teachers received extensive 2‐day training with the complete educational kit and teachers’ manual, to be able to implement the sessions later on. A family programme consisting of meetings, health fairs as well as information packets was sent home along with some food samples and recipes A ‘Health‐E‐PALS’ educational Kit with the following classroom posters (10) take‐home pamphlets (12 for each student) food diary booklet (1 for each student) PA booklet (1 for each student) set of 60 food cards board game: treasure game traffic lights signs food counter box (1 for each student) pedometers (1 for each student) A food service intervention targeting the school shops and the lunch boxes sent by the family (recommendations concerning the healthy list of snacks and drinks that should be available to children in the shop were provided to shop administrators. Posters encouraging healthy food choices were posted at the points of sales whenever possible). Students in the control schools received their usual curriculum during the intervention period. Diet and PA combination intervention vs control
Outcomes	Outcome measures Primary outcome: dietary habits, PA, screen time, knowledge, self‐efficacy, BMI, waist circumference Secondary outcomes: NR Process evaluation: reported (implementation, dose, context)
Implementation‐related factors	Theoretical basis: SCT Resources for intervention implementation: reported Who delivered the intervention: NR PROGRESS categories assessed at baseline: gender PROGRESS categories analysed at outcome: NR Outcomes relating to harms/unintended effects: NR Intervention included strategies to address diversity or disadvantage: adapted to the culture of Lebanese and Arab populations Economic evaluation: NR
Notes	Funding: this research was funded by an Eastern Mediterranean Regional Office Special Grant for Research in Priority Areas of Public Health (EMRO/WHO) Failure to succeed in modifying the school’s food environment due to lobbying and lack of support of some of the school authorities. Lebanon is a politically unstable context, with security threats and social unrests.
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Coin toss used to randomise schools. Quote: "Then, within each matched pair, one school was randomly assigned (by the toss of a coin) to receive the intervention, and the other school served as the control. Ultimately, four schools received the intervention (2 private and 2 public) and four others were control schools."
Allocation concealment (selection bias)	High risk	NR, but assume 'High risk' as coin tossing is easily subverted.
Blinding (performance bias and detection bias) All outcomes	Unclear risk	NR
Incomplete outcome data (attrition bias) All outcomes	Low risk	Very low attrition (3%) balanced in each group
Selective reporting (reporting bias)	Unclear risk	Protocol/trial registration document were unavailable
Other bias	Low risk	No additional threats to validity
Other bias‐ timing of recruitment of clusters	Low risk	Figure suggests that recruitment happened prior to randomisation.