The purpose of the study was to test the moderating influence of two risk factors, maternal depression and socio-economic status (SES), on the association between authoritarian and permissive parenting styles and child obesity.

Correlational, cross-sectional study. Parenting style was measured with the Parenting Styles and Dimensions Questionnaire (PSDQ). Maternal depression was measured using the Center for Epidemiologic Studies Depression Scale (CES-D). BMI-for-age percentile was used to categorize children by weight status (children with BMI-for-age ≥95th percentile were classified as obese). SES was computed from parent education and occupational status using the four-factor Hollingshead index.

Rural public schools in a mid-western state in the USA.

One hundred and seventy-six mothers of first-grade children (ninety-one boys, eighty-five girls) enrolled in rural public schools.

Both maternal depression and SES were found to moderate the permissive parenting style/child obesity association, but not the authoritarian/child obesity association. For depressed mothers, but not for non-depressed mothers, more permissive parenting was predictive of child obesity. Similarly more permissive parenting was predictive of child obesity among higher SES mothers, but not for lower SES mothers.

Maternal depression and SES interact with permissive parenting style to predict child obesity. Future research should examine the relationship among these variables using a longitudinal design.

During the early years, parents have a major influence on children's diets and developing food choices. We investigated parenting styles as predictors of 2–5-year-old children's diets and whether general nutrition knowledge (GNK) mediated these influences.

Cross-sectional research. Questionnaires measured demographic and lifestyle variables, family environment, parenting styles and feeding practices, child diet and GNK. Regression models tested GNK as a mediator of relationships between parenting variables and child diet (fruit/vegetable and non-core food consumption), controlling for confounders and family environment.

Questionnaires were completed by main caregivers at home.

Parents of children aged 2–5 years (n 269).

Higher child fruit/vegetable consumption was associated with lower over-reactive parenting and restriction, higher authoritative parenting and dining together as a family; with lax parenting approaching statistical significance (P = 0·083) and 19 % of variance explained by the model. GNK was not a significant predictor. Conversely, non-core food consumption was associated with higher over-reactive and lax parenting as well as child age, increased takeaway food consumption and higher television viewing; GNK had a small effect (P = 0·043) and 28 % of variance was explained by the model. GNK was a significant mediator only for authoritative parenting on non-core food (effect = −0·005).

These findings highlight that young children's diets may be improved by interventions targeting a range of positive and supportive parenting practices in conjunction with nutrition knowledge education for parents of young children. Further insights will come from closer attention to the nature and role of restrictive feeding practices v. laxness and longitudinal research.

To assess the prevalence of anaemia in rural Vietnam and to determine its risk factors.

A cross-sectional survey.

Vietnam, Nghe An Province.

The total number of participants was 439. Of these participants, one was excluded from the study due to a mental disorder. Forty-seven did not participate in the test for parasites and 68 did not complete at least one of the questions.

The prevalence of anaemia (haemoglobin (Hb) < 11.0 g dl−1) was 43.2% and of severe anaemia (Hb < 8.0 g dl−1) was 0.5%. Taking iron tablets, the consumption of eggs and the preference for Western medicine significantly and positively correlated with Hb concentration in the pregnant women in a multiple regression analysis. Pregnancy duration and hookworm infestation significantly and negatively correlated with Hb concentration in the pregnant women.

The prevalence of anaemia in rural Vietnam has remained as high as that found in the national anaemia survey in 2000. The results of the present study could aid in the development of an iron-deficiency anaemia programme among pregnant women in rural Vietnam that emphasises iron supplementation, parasite control and improved diet, including the consumption of eggs. The programme's focus should be on women who prefer traditional medicine to Western medicine.

The present study examined whether characteristics such as quality, selection and convenience are associated with dietary intake of fruits and vegetables independent of perceived costs in an inner-city, low-income population.

Secondary analysis of baseline data from a social marketing intervention designed to change household dietary practices among parents of 3- to 7-year-old children.

A community sample drawn from six low-income, primarily minority neighbourhoods in Chicago, IL, USA.

From the parent study, 526 respondents completed the baseline survey and were eligible for inclusion. Of this number, 495 provided complete data on sociodemographic characteristics, fruit and vegetable consumption, perceptions of the shopping environment, perceived costs of fruits and vegetables, and food shopping habits.

Logistic regression analysis showed that more positive perceptions of the food shopping environment were associated with greater consumption of fruits and vegetables. There was an increase of approximately twofold in the likelihood of consuming three or more fruits and vegetables daily per level of satisfaction ascribed to the shopping environment. This association was independent of perceived cost, store type and sociodemographic characteristics.

Our data show that among a generally minority and low-income population, quality, selection and convenience are important determinants of fruit and vegetable consumption. Nutrition promotion campaigns that aim to alter the built environment by increasing access to fruits and vegetables should recognize that simply increasing availability may not yield beneficial change when characteristics of the shopping context are ignored.

To assess the impact of urbanisation on the prevalence of the metabolic syndrome in Chinese adults.

As part of a community-based cross-sectional survey conducted in 2002, a sample from rural and urban populations in East China was obtained. The metabolic syndrome is defined by the National Cholesterol Education Program Adult Treatment Panel III criteria (ATP III) and the modified ATP III, which recommended a lower waist circumference cut-off for Asians.

Field sites in Jiangxi and Anhui provinces and the Jing'an District of Shanghai, China.

A total of 529 non-pregnant, non-lactating urban and rural adults, aged 20–64 years without diagnosed diabetes.

Dwelling in urban areas was associated with higher dietary fat intake and slightly lower total energy intake, and with significantly lower occupational physical activity. Using the ATP III criteria, the prevalence of the metabolic syndrome was significantly higher for urban than rural men (12.7 vs. 1.7%, P < 0.001), and was similar between urban and rural women (10.1 vs. 9.7%, P = 0.17). These urban–rural differences were greatly enhanced when the modified ATP III criteria for the syndrome were used, for men (34.3 vs. 2.7%, P < 0.01) and women (24.1 vs. 11.4%, P = 0.07). The Asian waist circumference cut-offs (90 and 80 cm for men and women, respectively) had a better combination of sensitivity and specificity in identifying other metabolic disorders, which included high glucose, high blood pressure, high triglycerides and low high-density lipoprotein cholesterol, for this population.

For the Chinese population, urban dwelling was associated with higher prevalence of the metabolic syndrome, especially in men.

Corner stores, also known as bodegas, are prevalent in low-income urban areas and primarily stock high-energy foods and beverages. Little is known about individual-level purchases in these locations. The purpose of the present study was to assess corner store purchases (items, nutritional characteristics and amount spent) made by children, adolescents and adults in a low-income urban environment.

Evaluation staff used 9238 intercept surveys to directly examine food and beverage purchases.

Intercepts were collected at 192 corner stores in Philadelphia, PA, USA.

Participants were adult, adolescent and child corner store shoppers.

Among the 9238 intercept surveys, there were 20 244 items. On average, at each corner store visit, consumers purchased 2·2 (sd 2·1) items (1·3 (sd 2·0) foods and 0·9 (sd 0·9) beverages) that cost $US 2·74 (sd $US 3·52) and contained 2786·5 (sd 4454·2) kJ (666·0 (sd 1064·6) kcal). Whether the data were examined as a percentage of total items purchased or as a percentage of intercepts, the most common corner store purchases were beverages, chips, prepared food items, pastries and candy. Beverage purchases occurred during 65·9 % of intercepts and accounted for 39·2 % of all items. Regular soda was the most popular beverage purchase. Corner store purchases averaged 66·2 g of sugar, 921·1 mg of sodium and 2·5 g of fibre per intercept. Compared with children and adolescents, adults spent the most money and purchased the most energy.

Urban corner store shoppers spent almost $US 3·00 for over 2700 kJ (650 kcal) per store visit. Obesity prevention efforts may benefit from including interventions aimed at changing corner store food environments in low-income, urban areas.

To evaluate the feasibility of diet mediterranisation, in a food-at-work context, and its consequence on metabolic syndrome in a mid-age unselected healthy male population group.

One-year longitudinal intervention study. Physical exercise was not modified.

All workers of the Santiago division of ‘Maestranza Diesel’, a metal-mechanic company servicing the mining industry, were invited to participate.

Initially, 145 workers of a total of 171, of average age 39 years, accepted to participate (sixteen women and 129 men). A subgroup of ninety-six men fully completed the controls programmed for the intervention study. Losses from the original group correspond to missing one control (sixteen), leaving the company (eleven) or blood sampling discomfort (six). The women and sixteen male workers, hired post study initiation, did participate but were excluded from this 12-month analysis.

Diet mediterranisation was successful, reflected in the daily food consumption at the canteen and the evolution of the Mediterranean diet score (MDS) from 4·8 ± 1·4 to 7·4 ± 1·5 (limits 0–14). Some metabolic syndrome components showed statistically significant improvement and also statistically significant correlation with the MDS: waist circumference, HDL-cholesterol, systolic and diastolic blood pressure. After 12 months, the reversion rate for metabolic syndrome was 48 % (12/23) with an incidence rate of 4·1 % for new cases (3/73). In total, metabolic syndrome decreased from 24·0 % to 15·6 % (23/96 to 15/96) (P = 0·029).

Diet mediterranisation is feasible in a food-at-work intervention, affecting lunch consumption at the workers canteen and overall consumption evaluated with MDS, together with a significant reduction in metabolic syndrome.

To examine the use of nutrition and health claims on packaged foods commonly eaten in Ireland.

An assessment of the labels of packaged food products that are commonly eaten in Ireland to determine the level of use of nutrition and health claims. Where present, the exact text of the claims as observed was recorded for seventeen different food categories and the claims categorised in accordance with EU Regulation 1924/2006 on nutrition and health claims made on foods.

Four retailers in Dublin, Ireland.

Of the foods surveyed, 47·3 % carried a nutrition claim and 17·8 % carried a health claim. Frozen fruit & vegetables and Breakfast cereals were the food categories with the highest proportion of nutrition claims. The most widespread nutrition claim was that referring to ‘fat’ and, within this group, the most commonly used text was ‘low fat’. The largest category of health claims observed in the present survey was general health claims. Claims referring to the digestive system were the most common followed by claims that a product will ‘lower/reduce/regulate your cholesterol’. Yoghurt & yoghurt drinks was the food category with the highest proportion of health claims, of which improving or boosting the digestive system was the most common.

The use of nutrition and health claims on the Irish market is widespread. EU Regulation 1924/2006 requires monitoring of the market for these types of claims. The current study could provide baseline data for the food industry and regulators to monitor the development of this market in the future.

In recent decades, the prevalence of non-communicable diseases (NCDs), such as obesity, diabetes and cardiovascular disorders has increased worldwide; the objective here is to describe the situation in southern Mediterranean countries.

Data derived from surveys in the region countries showed that in 2002 more than 60% of all deaths in the southern Mediterranean region are attributed to NCDs. Cardiovascular diseases (CVD) caused from about 34.3 to 52% of all deaths, making it the major killer among NCDs. In almost all of the southern Mediterranean countries, CVD risk factors increased with age, affected more women and urban area and were significantly associated with obesity. The Mediterranean dietary pattern, generally recognised, as a healthy diet is still the model for southern Mediterranean population; however, following the rapid process of urbanisation, southern Mediterranean populations have changed their lifestyle and food habits and tend to shift from traditional food habit. Indeed, intake trends illustrate the fall in whole-grain intake with a rise in animal sources and vegetable oils. Dietary energy has been steadily increasing by approximately 1000 kcal per capita per day between 1965 and 2000, exceeding per caput energy requirements. Protein and carbohydrate contribution to the energy intake show only small deviations and fat contribution to the energy intake is low, whereas fibre intake is generally low and that of SFA is high. Also, sedentarity appears to play a critical role in the development of body fat and may be a risk indicator for features of metabolic syndrome.

The major goal to prevent CVD should begin by preventing obesity through physical exercise and healthy nutrition. The nutritional prevention policy required should encourage population to adhere to the Mediterranean model.

To validate an FFQ designed to estimate energy intake in children against doubly labelled water (DLW). To investigate how quality control and standard beverage portion sizes affect the validity of the FFQ.

Thirty healthy children, aged 4–6 years, participated. Total energy expenditure (EE) was measured by the DLW method during an observation period of 15 d. At the end of this period parents filled out an FFQ designed to assess the child’s habitual energy intake (EI) of the preceding four weeks.

Validation study in The Netherlands.

Thirty healthy children (fifteen boys and fifteen girls), aged 4–6 years.

Mean EI (6117 (sd 1025) kJ/d) did not differ significantly from mean EE (6286 (sd 971) kJ/d; P = 0·15); the mean EI:EE ratio was 0·98. The Pearson correlation coefficient between EI and EE was 0·62. The Bland–Altman plot showed no systematic bias and a constant bias close to zero. Less intensive quality control of the FFQ maintained the mean EI:EE ratio and decreased the correlation slightly. Using standard instead of individually measured beverage portion sizes decreased the mean EI:EE ratio, but maintained the correlation.

It can be concluded that the developed FFQ is a valid instrument to estimate mean energy intake in a group of 4- to 6-year-old children and performs reasonably well to rank the subjects with respect to energy intake. It is therefore a useful instrument to estimate energy intake in children in surveys and epidemiological studies in The Netherlands.

The aim of the present study was to describe the nature and extent of food marketing on popular children’s websites and food product websites in Australia.

Food product websites (n 119) and popular children’s websites (n 196) were selected based on website traffic data and previous research on frequently marketed food brands. Coding instruments were developed to capture food marketing techniques. All references to food on popular children’s websites were also classified as either branded or non-branded and according to food categories.

Websites contained a range of marketing features. On food product websites these marketing features included branded education (79·0 % of websites), competitions (33·6 %), promotional characters (35·3 %), downloadable items (35·3 %), branded games (28·6 %) and designated children’s sections (21·8 %). Food references on popular children’s websites were strongly skewed towards unhealthy foods (60·8 % v. 39·2 % healthy food references; P < 0·001), with three times more branded food references for unhealthy foods. Branded food references displayed similar marketing features to those identified on food product websites.

Internet food marketing uses a range of techniques to ensure that children are immersed in brand-related information and activities for extended periods, thereby increasing brand familiarity and exposure. The relatively unregulated marketing environment and increasing use of the Internet by children point to the potential increase in food marketing via this medium. Further research is required to investigate the impact of Internet food marketing on children’s food preferences and consumption, and regulatory options to protect children.

To assess the consumption of whole-grain foods in different age and sociodemographic groups in Great Britain, using data from two national surveys.

Cross-sectional analysis of the consumption of whole-grain foods.

The 1986–87 Dietary and Nutritional Survey of British Adults and the 1994–95 National Diet and Nutrition Survey of people aged 65 years and over.

In 1986–87, 2086 British adults aged 16–64 years; 1189 British adults aged 65 years and over in 1994–95.

In the 1986–87 survey population, consumption of whole-grain foods increased with age. Median consumption of whole-grain foods was 1 serving per week in 16–24-year-olds and 3 servings per week in the 35–64-year-olds (P <0.0001). In 1994–95, median consumption was 5 servings per week in adults aged 65 years and over. Overall, one-third of British adults ate no whole-grain foods on a daily basis, and less than 5% ate 3 or more servings per day. Manual occupation and smoking were consistently associated with a higher proportion of non-consumers and fewer servings per week of whole-grain foods, independent of age, sex, region and season (each P < 0.001). The main sources of whole-grain foods were wholemeal bread and breakfast cereals, which accounted for more than three-quarters of all servings.

Consumption of whole-grain foods in the adult UK populations is more prevalent in the non-smoking, higher socio-economic groups. Amongst consumers of whole-grain foods, the frequency is similar to that reported in the USA and Norway.

To assess current beverage consumption patterns and anticipated reaction to an added 20 % tax on these products.

A random-digit dialled telephone interview lasting 20 min was administered to assess demographics, beverage consumption behaviours and intentions regarding consumption of sugar-sweetened beverages in the event of an additional tax on these beverages.

Respondents were recruited throughout the USA.

The study included 592 adults.

Sixty-nine per cent of respondents reported consuming at least one pre-packaged sugar-sweetened beverage in the past week; those who consumed sugar-sweetened beverages averaged seven pre-packaged beverages per week. Ninety-one per cent knew that frequent consumption of soft drinks increases risk of obesity. Thirty-six per cent supported a tax on sugar-sweetened beverages with greatest support among those aged 18–24 years, those with BMI < 30 kg/m2 and those with higher levels of education (P < 0·05). Over one-third of respondents said that they would cut back on their sweetened beverage consumption in the event of an added 20 % tax on these beverages.

Our findings suggest that an added tax on these beverages could influence some to cut down on their consumption, reducing their risk of obesity and related illnesses.

To review and discuss the effect of n-3 polyunsaturated fatty acids (PUFA) from fish in the prevention and, primarily, in the treatment of coronary artery disease (CAD).

Overview of the literature.

Denmark.

There is good evidence that fish consumption may reduce the risk of CAD.

Fish can be recommended to reduce the risk of CAD both in healthy subjects and in patients with a high risk of CAD or with documented CAD. The use of fish oil concentrates can not be recommended in general, but may be considered in patients after a myocardial infarction or in patients with hypertriglyceridaemia. An increased intake of n-3 polyunsaturated fatty acids from fish may have substantial implications for public health and health economy by decreasing the risk of coronary events and sudden cardiac death.

To investigate changes in the consumption of fruits and vegetables in work-site canteens using the tools of continuous quality improvement, and to gain knowledge of practical strategies being effective in increasing the consumption.

Study design included baseline data collection, an 8 h training session for all canteen staff, goal setting, strategy development and implementation for each canteen, end-point data collection and a follow-up data collection 4 months from the end-point (1 year from baseline). The main outcome measurement was average grams of fruits and vegetables per lunch meal served per customer (net weight; potatoes not included).

Five workplaces in Denmark: a military base, an electronic component distributor, a bank, a town hall and a waste-handling facility.

Work-site canteen managers, staff and customers.

There were significant increases in the total consumption of fruits and vegetables for all five work-site canteens from baseline to end-point, 70 g per customer on average (67, 54, 39, 88 and 103 g, respectively). The follow-up data collection showed that the canteens either maintained or significantly increased consumption, the average increase being 95 g per customer compared with baseline (77, 60, 86, 70 and 183 g, respectively).

This study demonstrates a large potential for work-site canteens to increase customers' intake of fruits and vegetables at lunch and suggests a broad spectrum of strategies to compose meals that are both rich in fruits and vegetables and attractive to customers.

To assess socio-economic differences in three components of nutrition knowledge, i.e. knowledge of (i) the relationship between diet and disease, (ii) the nutrient content of foods and (iii) dietary guideline recommendations; furthermore, to determine if socio-economic differences in nutrition knowledge contribute to inequalities in food purchasing choices.

The cross-sectional study considered household food purchasing, nutrition knowledge, socio-economic and demographic information. Household food purchasing choices were summarised by three indices, based on self-reported purchasing of sixteen groceries, nineteen fruits and twenty-one vegetables. Socio-economic position (SEP) was measured by household income and education. Associations between SEP, nutrition knowledge and food purchasing were examined using general linear models adjusted for age, gender, household type and household size.

Brisbane, Australia in 2000.

Main household food shoppers (n 1003, response rate 66·4 %), located in fifty small areas (Census Collectors Districts).

Shoppers in households of low SEP made food purchasing choices that were less consistent with dietary guideline recommendations: they were more likely to purchase grocery foods comparatively higher in salt, sugar and fat, and lower in fibre, and they purchased a narrower range of fruits and vegetables. Those of higher SEP had greater nutrition knowledge and this factor attenuated most associations between SEP and food purchasing choices. Among nutrition knowledge factors, knowledge of the relationship between diet and disease made the greatest and most consistent contribution to explaining socio-economic differences in food purchasing.

Addressing inequalities in nutrition knowledge is likely to reduce socio-economic differences in compliance with dietary guidelines. Improving knowledge of the relationship between diet and disease appears to be a particularly relevant focus for health promotion aimed to reduce socio-economic differences in diet and related health inequalities.

To assess breast-feeding initiation and prevalence from birth to 6 months in a sample of mothers in Dublin, and to determine the factors associated with breast-feeding initiation and ‘any’ breast-feeding at 6 weeks in a sample of Irish-national mothers.

This prospective cross-sectional study involved the recruitment of women during the antenatal period, with subsequent follow-up of mothers who delivered healthy, term singleton infants, at 6 weeks and 6 months postpartum.

Participants were recruited from antenatal clinics in the Coombe Women and Infants University Hospital, Dublin.

In all, 401 Irish-national and forty-nine non-Irish-national mothers met the criteria for inclusion in the present study.

Breast-feeding initiation rates of the Irish-national and non-Irish-nationals were 47 % and 79·6 %, respectively. Factors that were significantly (P = 0·000) associated with both breast-feeding initiation and ‘any’ breast-feeding at 6 weeks included mothers who were ≥35 years, educated to third level, reported positive postnatal encouragement to breast-feed from their partners and had a positive antenatal intention to breast-feed. The maternal negative perception that breast-feeding is an embarrassing way to feed an infant was demonstrated as a major barrier to initiation.

Breast-feeding initiation and prevalence rates of the Irish-national population remain low and lag considerably behind national and international targets. Inclusion of the partner in breast-feeding promotional initiatives during the antenatal period may be crucial to increase breast-feeding rates in Ireland. Public health campaigns that focus on increasing the social acceptability of breast-feeding may prove effective in addressing this cultural barrier.

Women of lower educational attainment have less balanced and varied diets than women of higher educational attainment. The diets of women are vital to the long-term health of their offspring. The present study aimed to identify factors that influence the food choices of women with lower educational attainment and how women could be helped to improve those choices.

We conducted eight focus group discussions with women of lower educational attainment to identify these factors. We contrasted the results of these discussions with those from three focus group discussions with women of higher educational attainment.

Southampton, UK.

Forty-two white Caucasian women of lower educational attainment and fourteen of higher educational attainment aged 18 to 44 years.

The dominant theme in discussions with women of lower educational attainment was their sense that they lacked control over food choices for themselves and their families. Partners and children exerted a high degree of control over which foods were bought and prepared. Women’s perceptions of the cost of healthy food, the need to avoid waste, being trapped at home surrounded by opportunities to snack, and having limited skill and experience with food, all contributed to their sense they lacked control over their own and their family’s food choices.

An intervention to improve the food choices of women with lower educational attainment needs to increase their sense of control over their diet and the foods they buy. This might include increasing their skills in food preparation.

To determine the nutrient composition of complementary foods consumed by 6–12-month-old South African infants.

Nutrient intake was determined for infants who were recruited to participate in a randomised controlled trial using a single 24-hour dietary recall.

Infants aged 6–12 months (n = 475) residing in The Valley of a Thousand Hills, a rural area in KwaZulu-Natal, South Africa.

Energy and protein intakes from complementary foods were adequate. Infants who consumed infant products (commercially available fortified infant cereals/ready-to-eat canned baby foods/formula milk powder) had significantly higher intakes of calcium, iron, zinc, vitamin A, thiamine, riboflavin, niacin, vitamin B6, vitamin B12 and vitamin C than infants who did not consume any infant products. For infants who consumed infant cereals (n = 142), these cereals provided 51% of total iron intake. Infant cereals provided more than 25% of total intake for magnesium, thiamine, niacin and vitamin B12. For infants consuming ready-to-eat canned baby foods (n = 77), these products contributed less than 15% of total intake for all the micronutrients. The nutrient density of the complementary diet was less than half the desired density for calcium, iron and zinc. Animal products were consumed by 17% of infants, 26% consumed dairy products and 18% consumed vitamin-A-rich fruit and vegetables during the 24-hour recall period.

The nutrient composition of complementary foods among rural South African infants was inadequate, especially for iron, zinc and calcium. Strategies should be developed to improve the nutritional quality of their diets.

An increasing focus on legislation, policy and guidance on the nutritional content of school food has in part been in response to the limited impact of more behavioural or educational approaches. However, there is a risk that a sole focus on policy-level action may lead to neglect of the important contribution that more behavioural approaches can make as components of effective, coordinated, multilevel action to improve the dietary intake of schoolchildren. The current paper aims to highlight the potential importance of viewing alternative approaches as complementary or synergistic, rather than competing.

The socio-ecological and RE-AIM frameworks are used to provide a theoretical rationale and demonstrate the importance of explicitly identifying the interdependence of policies, interventions and contextual structures and processes. School food case study evidence is used to exemplify how understanding and exploiting these interdependencies can maximise impact on dietary outcomes.

Case studies of trials in schools in the UK (South West England and Wales) and Australia (Victoria).

Schoolchildren.

The case studies provide examples to support the hypothesis that the reach, effectiveness, adoption, implementation and maintenance of school food policies and interventions can be maximised by understanding and exploiting the interdependence between levels in the socio-ecological framework.

Rather than being seen as competing alternatives, diverse approaches to improving the diets of schoolchildren should be considered in terms of their potential to be complementary and synergistic, acting at multiple levels to improve acceptability, fidelity, effectiveness and sustainability.