OBJECTIVE:Nutrition claims on alcohol packaging are increasingly common, however little is known about how consumers interpret and understand them. This study examined exposure to and perceptions of nutrition claims among Australians who regularly drink alcohol, and identified predictors of positive attitudes towards claims. DESIGN:In a cross-sectional online survey, participants viewed mocked-up alcohol labels showing eight nutrition-related claims commonly found in the Australian market, indicated how frequently they recalled seeing each, and the extent to which it was perceived as true, understandable, important, and relevant. Chi-square tests examined associations between perceptions and consumer attributes, and linear regression identified predictors of positive attitudes. SETTING:Australia, 2024. PARTICIPANTS:2,028 adults (18+ years) who regularly (more than once monthly) drink alcohol and reside in Australia. RESULTS:Claims about carbohydrates (32%) and sugar (31%) were most frequently recalled, and perceived to be true, relevant, and easy to understand by approximately half of participants. Most participants considered access to claims' content important, particularly sugar (76%) and calories (73%). Younger age, higher claim awareness, and greater claim exposure significantly (p<.05) predicted positive attitudes across most claims, while female gender predicted positive attitudes towards sugar, calorie, and vegan claims. The significance of other characteristics varied by claim type. CONCLUSIONS:Alcohol nutrition claims are salient to many consumers and generally interpreted positively. These findings highlight the appeal of claims in alcohol contexts and underscore the need to consider regulatory options- including mandated health warning labels -to address this subtle marketing tactic and support informed choices.
Abstract Objective: We examined the effects of price interventions on the healthiness of a hypothetical food order in a simulated online out-of-home food delivery app. Design: The design was a randomised controlled trial, with four conditions (10% taxation of less healthy menu items; 10% subsidy of healthier menu items; a combination of taxation and subsidy; standard pricing) and recruitment was stratified by socioeconomic position (SEP). Primary outcomes were healthier vs less healthy main meal selected and total kilocalories (kcals) selected. Setting: Participants selected a hypothetical evening meal from out of home food outlets on a simulated online food delivery app. Participants: N=3107 adult participants from the UK were randomised into taxation (n=750), subsidies (n=808), a combination of taxation and subsidies (n=769), and standard pricing (n=779). 57–58% of participants were higher SEP. Results: There were no statistically significant effects of the pricing interventions on whether a healthy vs less healthy main meal was selected (e.g. taxation vs control OR 0.91 (95% CI 0.74, 1.12); subsidies vs control OR 1.08 (95% CI 0.89, 1.31)) or on total kcals selected (e.g. taxation vs control regression coefficient -44.31 (95% CI -95.90, 7.28); subsidies vs control regression coefficient -7.94 (95% CI -60.23, 44.35)). There was no evidence that effects differed by SEP. Conclusions: We found no convincing evidence that 10% changes in price of healthy and less healthy food in a simulated out of home food delivery app impacted on healthiness of food selected. Further research may benefit from examining effects of larger price changes and in real-world purchasing conditions.
Abstract Objective: To assess the prevalence and formatting of voluntary alcohol, nutrition, and ingredient information on the labels of alcoholic beverages sold in the U.S. in 2021. Design: We assessed labels from the top 150 beer, spirits, and wine brands from 2021. Primary outcomes were presence of: 1) Statement of Average Analysis (SAA; includes calories, carbohydrates, fat, protein); 2) Serving Facts (SAA plus serving size, servings per container, alcohol content); and 3) ingredients lists. We also assessed prevalence of nutrition- and ingredient-related claims. Attributes were considered present for a brand if they appeared on the label of at least one product from that brand. We used Fisher’s exact tests to assess associations between primary outcomes and beverage characteristics. Setting: Labels were from a government-run label approval database. Participants: Unit of analysis was brands. Results: The analysis included 925 labels from 65 beer, 93 spirits, 101 wine brands. Forty-one beer brands (63%), 24 spirits brands (26%), and 2 wine brands (2%) had SAAs. Eighteen beer brands (28%), 11 spirits brands (12%), and no wine brands had Serving Facts statements. Eleven beer brands (17%), but no spirits or wine brands, had ingredients lists. Presence of SAA was positively associated with having calorie or carbohydrate claims (beer and spirits), larger market share (beer only), and being a member of the beer industry’s Brewers’ Voluntary Disclosure Initiative (beer only) (p<0.05). Conclusion: Low uptake of voluntary nutrition and ingredient information by top beer, spirits, and wine brands suggests the need for mandatory standardized labels.
OBJECTIVE:To examine pharmacy professionals' involvement in nutrition care, including the nutrition advice and services they provide, perceived barriers and facilitators, and resource needs for integrating nutrition into pharmacy practice. DESIGN:Mixed-methods cross-sectional survey comprising quantitative items on knowledge, attitudes and practices, and open-ended questions analysed thematically. SETTING:Online survey administered via Qualtrics. PARTICIPANTS:UK-based pharmacy professionals aged ≥18 years (N = 220). RESULTS:Nutrition advice was most frequently provided for diabetes (68.4%), cardiovascular disease (CVD) risk factors (64.1%), dietary supplements (49.3%) and weight management (48.3%). Knowledge was strongest for food-drug interactions and supplements, but weakest for sustainable diets and national dietary guidelines. Higher perceived knowledge was significantly associated with providing advice on diabetes, obesity, CVD and malnutrition (all p < 0.05). Nutritional assessment practices were limited: 67.7% of participants did not conduct nutritional screening, and 70.2% did not perform dietary assessments. Overall, 65.3% reported that nutrition training is essential. Key barriers included limited education, practical resources, unclear referral pathways, and challenges initiating nutrition conversations, while respondents highlighted strong needs for practice-specific tools and collaboration with dietitians. CONCLUSIONS:Pharmacists commonly provide nutrition support for key NCD areas, yet provision remains inconsistent. Persistent gaps in knowledge, training, and practical resources, combined with unclear referral pathways, limit their capacity to deliver nutrition care. Strengthening nutrition education, developing pharmacy-focused resources, and enhancing interprofessional collaboration could enable more effective, integrated nutrition support in primary care.
OBJECTIVE:Consumption of meat - red and processed meat in particular - exceeds recommended levels in most high-income countries. Higher taxes on meat have been proposed as a response but have proven difficult to implement due to political controversy. We examined the role of framing in the media debate on taxing meat and other animal-based foods in Germany. DESIGN:We conducted a framing analysis to identify themes characterising the debate, and key actors and their narrative and argumentative strategies. SETTING:Germany. PARTICIPANTS:A total of 381 articles from eighteen German-language newspapers published between 2019 and 2023. RESULTS:Frames in favour of higher meat taxes most commonly referred to potential animal welfare and environmental gains, with health playing a smaller role. Anti-tax frames most commonly concerned the amplification of inequalities, the alleged inefficacy of taxes and the superiority of regulation. Support for higher taxes came from across the political spectrum and from various stakeholders, including producers, researchers and environmental organisations. Conservative actors and producers often expressed support, conditional upon earmarking of revenue for animal welfare measures. CONCLUSIONS:Using framing strategies and policy designs that appeal to broadly shared values may help to reduce polarisation in debates on meat taxation. In countries where concerns for animal welfare are salient, earmarking revenue for animal welfare improvements may increase support. Anticipating and addressing concerns around equity and efficacy may help to defuse criticism. In the German context, legal obstacles to earmarking and rising inflation may have hindered policy adoption.
Abstract Objective: Exposure to food advertising is associated with consumption. Globally, most outdoor food advertisements feature unhealthy foods or beverages. As Australian local government areas (LGAs) begin developing restriction policies, the feasibility of applying nutrient-based Nutrition Classification Systems to outdoor advertising requires evaluation. Design: Observational study on 1) types of food business advertisements outdoors and 2) availability of quantitative nutrition and/or ingredient information for featured products. 178 outdoor advertisements were analysed, from a 500m audit around schools in 16 stratified LGAs (2019), along with bus shelter audits in four LGAs (2022). Advertisements were categorised as featuring ‘branded packaged products’, ‘food service product - chain’, ‘food service product - independent’, ‘branding only’, or ‘incidental food/beverage’. For packaged or food service advertisements, online searches were conducted to identify product-specific nutrition information. Setting: Metropolitan Perth, Australia. Results: Advertisements featured packaged products (34% of advertisements); food service products - chain (21%); independent (16%); incidental food/beverage (18%); and branding only (11%). Nutrition information was located for 70% of packaged products and 68% of chain food service advertisements. Independent food service outlets provided no nutrition data and rarely depicted identifiable products. Overall, nutrition information was available for 45% of advertisements, and ingredient information for 35%. Conclusions: The limited availability of quantitative data constrains the application of nutrient-based nutrition classification systems. A system based primarily on food categories, with nutrient limits for some categories, and a robust approach to brand advertising likely offers a practical and impactful approach for LGAs seeking to restrict unhealthy outdoor food advertising.
OBJECTIVE:To explore consumers' understanding of whole-grain foods and their processing and food industry personnel's perceptions of whole-grain foods in processing classification systems. DESIGN:Semi-structured focus groups and interviews. SETTING:Online. PARTICIPANTS:Consumers (n 28) ≥ 18 years frequently purchasing/consuming grain foods. Food industry personnel (n 16) currently/recently employed within the grain industry. RESULTS:Consumers generally used whole-refined grain comparisons to gauge the level of processing, perceiving whole grains as less processed. While some suggested processing elements, such as additives, may influence their food choices, healthfulness was typically judged based on the presence or absence of certain nutrients. Often, other drivers of behaviour took precedence (e.g. cost, familial preferences and culinary skills). Food industry personnel viewed food processing as complex but oversimplified in current food processing classification systems. They considered that while some processed foods can be unhealthful, this does not apply to all processed foods. They emphasised the importance of holistic consumer education including that processing needs to be considered together with the food's nutritional composition to help consumers differentiate between less healthy and 'healthier' processed foods (e.g. a highly processed refined grain food with added fats and sugars, and a fortified whole-grain product). CONCLUSIONS:Messaging around food processing should be considered alongside those on nutritional quality of foods to ensure consumers are informed in their understanding of a food's healthfulness. Policy measures addressing food processing should reflect its complexities, including the different types and functions of processing and their rationale, particularly in the context of whole grains.
Abstract Objective: To explore how key stakeholders contribute to dietary self-care support for adults with type 2 diabetes receiving outpatient care in diabetes clinics in the Ashanti Region of Ghana. Design: Descriptive phenomenological study. Purposive sampling technique was used to recruit the participants. A total of 31 interviews were conducted using a semi-structured interview guide. Reflexive thematic analytical framework was followed to analyse the data. Setting: Diabetes clinics in the Ashanti region of Ghana: Komfo Anokye Teaching Hospital, Manhyia District Hospital, Ejisu Government Hospital, and Juaben Government Hospital. Participants: healthcare providers, family caregivers, and officials of health directorates. Results: Healthcare professionals contributed to dietary self-care by framing and interpreting dietary knowledge, offering psychological care and support, and preparing family caregivers for their caregiving responsibilities. Family caregivers supported adherence by providing emotional reinforcement and behavioural motivation, assuming responsibility for managing the daily realities of dietary self-care, and mobilising material and financial resources. Directors and officers at the health directorate contributed through supervision and quality control, and through capacity building. Conclusion: The study underscores a need for continuous professional development programmes for healthcare providers, equipping them with updated knowledge on dietary counselling, psychological support, and caregiver training. Additionally, the role of health directorates in supervising healthcare facilities and facilitating training programmes underscores the importance of strengthening institutional frameworks that ensure adherence to evidence-based dietary guidelines. Furthermore, the study highlights a need for healthcare facilities to strengthen the recognition and formalisation of the role of family caregivers in diabetes self-care practices.
OBJECTIVE:Describe the food environment in an urban African township by examining the availability, quality, pricing and promotion of food items in areas of higher and lower deprivation, defined according to household income, unemployment and economic activity, dwelling type and basic service availability. DESIGN:Cross-sectional study applied an adapted Environmental Profile of Community Health (EPOCH) tool to audit the food environment. Data were collected on food outlets (formal, informal, food service, and specialty stores), grocery item quality and pricing and product advertising. SETTING:Four areas (∼7.8 km2) of Soweto, South Africa, purposively selected by deprivation level. PARTICIPANTS:This study did not involve human participants. RESULTS:We audited 241 routes, identifying 1899 food outlets (1169 lower-, 730 higher-deprivation). Outlet distribution differed by deprivation (p<0.001): supermarkets were more common in lower-deprivation areas (6.5% vs 1.1%), while convenience stores selling cigarettes were more prevalent in higher-deprivation areas (9.0% vs 3.8%). Fast-food outlets dominated both settings, though alcohol stores and pubs were more frequent in higher-deprivation areas. Specialty and informal outlets, fruit and vegetable quality and pricing, did not differ significantly. While some food items were marginally more expensive in lower-deprivation areas, the difference was modest. Advertising patterns varied, with more packaged snack and alcohol advertisements in lower-deprivation areas and more sugar-sweetened beverage advertisements in higher-deprivation areas (p<0.01). CONCLUSION:Findings highlight the need to expand healthy food access in higher-deprivation areas and regulate unhealthy food advertising in lower-deprivation areas. Context-specific interventions are essential to promote equitable, health-supporting food environments in Soweto.
Food insecurity among international graduate students in the USA is a nutrition equity challenge that remains largely unaddressed by the nutrition science community. Prevalence estimates range from 22 % to 46 % across institutions, substantially exceeding the national household average, driven by converging financial constraints, restricted employment opportunities and limited access to culturally appropriate foods. These conditions promote rapid dietary acculturation towards energy-dense, low-nutrient food patterns with well-established associations with insulin resistance, hypertension and cardiometabolic risk. Despite a growing empirical base, longitudinal evidence on dietary quality and health outcomes in this population is virtually absent, and university nutrition support systems are poorly adapted to the cultural dietary needs of an internationally diverse student body. This commentary calls on nutrition researchers, dietitians and universities to recognise food insecurity among international graduate students as a substantive public health nutrition concern warranting targeted research and culturally responsive institutional action.
Abstract Objective: Price promotions are widely used in supermarkets and are more commonly applied to less healthy foods and beverages. We aimed to examine how supermarket price promotions influence food and beverage purchasing among households with school-aged children in Australia, and how perceptions vary by income. Design: A cross-sectional qualitative study using semi-structured interviews, analysed using thematic analysis. Setting: Australia, within the supermarket retail food environment. Participants: Twenty-two parents or caregivers of school-aged children from households with differing income levels. Results: Participants across income groups reported using supermarket price promotions as a budgeting strategy, particularly in the context of rising food costs. Price promotions were described as encouraging unplanned purchases, most often for unhealthy foods and beverages. Compared with higher income households, lower income households reported greater awareness of supermarket pricing strategies and more frequent purchasing of price-promoted products. Participants perceived that healthy options were less frequently discounted, and suggested that increasing promotions for healthy foods and beverages would better support healthy diets. Conclusions: Supermarket price promotions were perceived to shape purchasing decisions, often encouraging purchases of less healthy foods and beverages. Regulatory approaches that reduce promotions on less healthy products while improving the affordability of healthier options may support healthier and more equitable food environments, particularly for households experiencing financial constraints.
OBJECTIVE:To examine global, regional and national trends in dietary fibre and added sugar consumption and to assess their implications for non-communicable disease (NCD) prevalence. DESIGN:This study used a longitudinal ecological design. Dietary fibre (1990-2018) and added sugar (1990-2020) intake data were obtained from the Global Dietary Database (GDD). Intakes were analysed across GDD regions, age groups, education levels and urbanisation status. Subsequently, mixed-effects models were used to assess the association between NCD prevalence and intakes of fibre, added sugar and the fibre-to-added-sugar ratio, adjusting for socio-demographic index (SDI), national income and urbanisation. SETTING:The GDD covers dietary intake estimates for 185 countries and territories. RESULTS:Globally, median dietary fibre intake rose from 14·8 to 21·6 g/d, while added sugar intake increased from 7·7 % to 10·5 % of total energy intake. Fibre intake increased in all regions except high-income countries, where it declined from 21·5 to 16·4 g/d. In contrast, added sugar intake increased in all regions except Latin America and the Caribbean (15·6 % to 13·3 % of total energy). Intake patterns were associated with education and urbanisation levels, with higher added sugar intake observed in countries with a higher SDI (r = 0·195, P = 0·008). The association between dietary fibre-to-added-sugar ratio was not significantly associated with NCD prevalence (β = -10·15, P = 0·067). CONCLUSIONS:This study highlights global disparities in dietary fibre and added sugar consumption, driven by regional, educational and urbanisation factors. These findings underscore the need for targeted interventions to improve nutrition and reduce the NCD burden.
OBJECTIVE:Food insecurity is prevalent among underserved communities and contributes to maternal-child health disparities. The perinatal period - from pregnancy through 1 year postpartum - provides a critical window of opportunity to identify and address food insecurity. However, perinatal providers face barriers that prevent them from providing screening, referrals and follow-up services. The study aimed to understand barriers perceived by perinatal providers to implement strategies to screen, refer and follow up for food-insecure pregnant people and children living in underserved areas. DESIGN:This qualitative phenomenological study explored multi-level barriers perceived by perinatal providers when implementing strategies for screening, referral and follow-up for food insecurity guided by the socio-ecological model. SETTING:This study was conducted within five zip codes of Southern Nevada (89101, 89106, 89030, 89031 and 89032) selected for their prevalence of food insecurity and health disparities. PARTICIPANTS:Semi-structured interviews were conducted with fifteen perinatal providers. RESULTS:Barriers at the individual provider level included lack of knowledge and education on food insecurity; at the interpersonal level included patient hesitancy to reveal sensitive information to providers; at the institutional level included lack of standard procedures to conduct screening, referrals and follow-up services; and at the community and policy levels identified organisational capacity and historical distrust of healthcare systems as obstacles to offering equitable care for food insecurity in perinatal settings. CONCLUSION:Addressing these multi-level barriers is essential to implementing effective food insecurity mitigation strategies within perinatal care settings. Utilising the created recommendations may promote equitable care for food insecurity within clinical and community perinatal settings.
OBJECTIVE:This study aims to investigate the impact of women's empowerment on child undernutrition from 2006 to 2021 in India at the state, primary sampling unit and household levels. DESIGN:This study uses repeated cross-sectional data from three rounds of the National Family Health Survey (NFHS). Child undernutrition is assessed using stunting, wasting and underweight indicators, with women's empowerment as a key predictor. Kernel density and linear polynomial plots depict the progression of anthropometric indicators over time, while multilevel regression identifies correlates and clustering in the undernutrition outcome. PARTICIPANTS:Children under 5 years of age from all twenty-eight states and nine union territories of India living with their biological mothers, who are currently married or in union and not pregnant, were included in the study. RESULTS:Findings indicate that NFHS-5 reports the lowest prevalence of stunting and underweight, while severe wasting persists across all survey rounds. Women's empowerment was not significant in NFHS-3, emerged as a significant determinant by NFHS-5 (NFHS-3 β = -0·08 (-0·26, 0·11); NFHS-5 β = -0·29** (-0·51, -0·07)). Among covariates, wealth quintile showed the strongest influence on child undernutrition from 2006 to 2021, with children from the richest households having the lowest risk of being underweight. Clustering remained higher at the household level in all survey rounds, reflected through the intra-class correlation. CONCLUSIONS:Higher women's empowerment is significantly associated with reduced child undernutrition, where higher clustering persists at the household level. These findings highlight the need for targeted policies promoting women's empowerment through community platforms and convergence with self-help groups to strengthen household-level health and nutrition outcomes.
OBJECTIVE:The environments where individuals live can shape their dietary patterns, but research using intersectionality as a context-informed analytic tool to assess associations between neighbourhood deprivation and diet quality is lacking. We therefore examined whether four dimensions of neighbourhood deprivation were independently and/or jointly associated with diet quality among adults in Canada. DESIGN:We used 24-h dietary recall data to calculate Healthy Eating Index (HEI-2015) scores to assess diet quality and the 2016 Canadian Marginalisation Index (CAN-Marg) to assess four dimensions of neighbourhood deprivation (material resources, immigration/visible minority, age/labour force and households/dwellings). Weighted linear regression models were used to examine whether these CAN-Marg dimensions were independently and/or jointly associated with diet quality, adjusting for individual, household and area characteristics. SETTING:The ten Canadian provinces. PARTICIPANTS:Adults (≥ 18 years) who participated in the 2015 Canadian Community Health Survey-Nutrition. RESULTS:The material resources (β = -0·955, 95 % CI = -1·438, -0·471) and immigration/visible minority (β = 0·768, 95 % CI = 0·268, 1·268) dimensions were independently associated with HEI-2015 scores. Significant interactions suggest the associations between living in a neighbourhood with less material resources and lower HEI-2015 scores were stronger in areas with a smaller proportion of recent immigrants/visible minorities (β = 0·521, 95 % CI = 0·174, 0·868) and non-working individuals (β = -0·643, 95 % CI = -1·052, -0·234). CONCLUSION:Neighbourhood material deprivation was not uniformly associated with poor diet quality. This suggests that associations between neighbourhood deprivation and diet quality are not universal and vary across neighbourhoods with differing immigrant, visible minority, age and labour force compositions.
South Asia presents a striking nutritional paradox: populations among the world's highest fish consumers carry disproportionate cardiometabolic risk at BMI levels well below disease thresholds for European populations. Marine fish is established as cardioprotective in fatty-fish-consuming coastal populations, yet this benefit appears to break down in South Asian contexts. This commentary interrogates four interlocking mechanisms. First, aquaculture-driven species substitution has replaced n-3-rich species such as hilsa and coastal sardines with leaner farmed varieties offering only a fraction of the cardioprotective lipid profile. Second, deep frying in high-n-6 oils substantially degrades PUFA bioavailability. Third, heavy metal co-contamination in arsenic- and mercury-affected watersheds may attenuate n-3 benefits. Fourth, urbanisation is eroding fish intake among the highest-risk subgroups, while aggregate dietary data obscure this heterogeneity. Generic eat-more-fish guidance is insufficient; ethnicity-sensitive, sustainability-conscious guidance on species, preparation and contamination risk is needed to realise fish's cardioprotective potential in South Asia.
OBJECTIVES:The effectiveness of food advertising restrictions may be limited by the allowance of brand advertising. This study investigated the impact of brand advertising on cognitive, affective and behavioural intention outcomes for food products high in fat, salt and/or sugar (HFSS). DESIGN:Online randomised controlled trial. Participants were randomly allocated to one of three groups: HFSS brand advertisements, non-HFSS brand advertisements or non-food brand advertisements (control). Eight images of brand advertisements were individually presented via an online research platform. The primary outcomes were purchase intention and craving, measured using 100-point slider scales. Secondary outcomes were brand recognition, recall and product associations. Generalised linear models examined craving and purchase intention for HFSS foods. Group differences in brand recognition, recall and product associations were tested using Kruskal-Wallis and ANOVA. SETTING:Online. PARTICIPANTS:UK adults (N 191) aged 18-87 (M = 47; sd = 16·15). RESULTS:The mean composite purchase intention score for the HFSS group (234·89) was not significantly different (p > 0·05) from coefficients for non-HFSS (-51·91) and non-food groups (31·21). Similarly, no significant group differences were found for cravings. The HFSS group was significantly more likely to recognise, recall and associate more products with viewed brands, compared to non-HFSS and non-food groups (ps < 0·01). CONCLUSION:Exposure to HFSS brand advertising triggered recognition, recall and product associations with viewed brands. However, this did not translate into increased craving or purchase intention for HFSS foods. Future research should examine the effects of brand advertising in real-world settings.
OBJECTIVE:This systematic review aimed to evaluate the effectiveness of nutrition interventions delivered in Outside School Hours Care (OSHC) services for children aged 4-12 years. DESIGN:Five electronic databases were searched for articles published up to February 2024. Eligible studies were quantitative evaluations of nutrition interventions conducted in OSHC settings, including randomised controlled trials, quasi-experimental and pre-post study designs. Study selection, data extraction and risk of bias assessments (ROB 2 and ROBINS-I tools) were conducted independently by two reviewers. SETTING:Formal OSHC services operating before and/or after school and during school holidays in high-income countries. Outcomes assessed included children's dietary intake, food provision, healthy eating behaviours, staff practices, service policies and health indicators such as BMI. PARTICIPANTS:Children (aged 4-12 years) and staff at OSHC services. RESULTS:Thirty-three studies involving approximately 13 880 participants were included. Interventions varied in duration (7 weeks to 3 years) and components, including nutrition education, staff training, family engagement, menu and policy changes and many also a physical activity component. Most studies reported improvements in food provision, children's dietary intake and staff nutrition practices. Interventions focused on food provision, menu planning and policy were most effective. Few studies reported significant changes in anthropometric outcomes. Risk of bias was moderate across studies. CONCLUSIONS:This review highlights effective strategies to improve children's dietary habits and food environments in OSHC services. Sustained interventions that focus on food provision, menu planning and/or policy are recommended. Future research should explore multi-level initiatives, digital tools, fidelity and cost-effectiveness.
