Restaurant kids' meal beverage offerings before and after implementation of healthy default beverage policy statewide in California compared with citywide in Wilmington, Delaware.

OBJECTIVE: In 2019, California and Wilmington, Delaware' implemented policies requiring healthier default beverages with restaurant kids' meals. The current study assessed restaurant beverage offerings and manager perceptions. DESIGN: Pre-post menu observations were conducted in California and Wilmington. Observations of cashiers/servers during orders were conducted pre-post implementation in California and post-implementation in Wilmington. Changes in California were compared using multilevel logistic regression and paired t tests. Post-implementation, managers were interviewed. SETTING: Inside and drive-through ordering venues in a sample of quick-service restaurants in low-income California communities and all restaurants in Wilmington subject to the policy, the month before and 7-12 months after policy implementation. PARTICIPANTS: Restaurant observations (California n 110; Wilmington n 14); managers (California n 75; Wilmington n 15). RESULTS: Pre-implementation, the most common kids' meal beverages on California menus were unflavoured milk and water (78·8 %, 52·0 %); in Wilmington, juice, milk and sugar-sweetened beverages were most common (81·8 %, 66·7 % and 46·2 %). Post-implementation, menus including only policy-consistent beverages significantly increased in California (9·7 % to 66·1 %, P < 0·0001), but remained constant in Wilmington (30·8 %). During orders, cashiers/servers offering only policy-consistent beverages significantly decreased post-implementation in California (5·0 % to 1·0 %, P = 0·002). Few managers (California 29·3 %; Wilmington 0 %) reported policy knowledge, although most expressed support. Most managers wanted additional information for customers and staff. CONCLUSIONS: While the proportion of menus offering only policy-consistent kids' meal default beverages increased in California, offerings did not change in Wilmington. In both jurisdictions, managers lacked policy knowledge, and few cashiers/servers offered only policy-consistent beverages. Additional efforts are needed to strengthen implementation of kids' meal beverage policies.

A Safety Net Unraveling: Feeding Young Children During COVID-19.

The emergence of COVID-19 in the United States led most states to close or severely limit the capacity of their early child-care and education (ECE) programs. This loss affected millions of young children, including many of the 4.6 million low-income children who are provided free meals and snacks by their ECE programs through support from the federal Child and Adult Care Food Program (CACFP).Although Congress swiftly authorized waivers that would allow CACFP-participating ECE programs to continue distributing food to children, early evidence suggests that most ECE programs did not have the capacity to do so, leaving a fragmented system of federal, state, and local food programs to fill the gaps created by this loss.Critical steps are needed to repair our nation's fragile ECE system, including greater investment in CACFP, to ensure the nutrition, health, and development of young children during the COVID-19 pandemic and beyond.

The Use of Infant Confinement Equipment in Community-Based Child Care Centers: An Analysis of Centers Participating in a Statewide Quality Rating and Improvement System.

Objectives Although infants increasingly spend time in community-based child care centers, little attention has been paid to their physical activity experiences while in group care. In particular, the use of devices to restrict infant mobility, such as bouncy seats, high chairs, cribs, and stationary activity centers, has received little attention in the physical activity literature. The current study examines the presence and use of these confinement devices in infant classrooms. Methods A secondary analysis of observational data in child care centers participating in Delaware's Quality Rating and Improvement System was conducted. Quality assessment observations were coded for the use of confinement devices and the actual amount of time the confinement device was employed per child. The sample consisted of 38 infant classrooms serving a total of 162 infants in the statewide system. Results Findings suggest a high level of utilization of confinement devices in infant child care classrooms with each classroom averaging three pieces of equipment used during the observations and 22% of observed children being confined 30 min or longer during the observation period. Conclusions for Practice The reliance on confinement devices in group child care is a potential concern in the quest to prevent childhood obesity by ensuring adequate physical activity and mobility for infants in group care settings. More research is needed to understand the implications of the use of confinement devices on physical activity in group care settings.

Demographic and service-use profiles of individuals using the CarePayment program for hospital-related medical debt: results from a nationwide survey of guarantors.

BACKGROUND: Many Americans find themselves with problems paying medical bills, and medical debt can lead to numerous negative financial, social and access to healthcare outcomes. One potential market-based solution to these challenges is to provide financing options that have patient-friendly terms while complying with increasingly complex federal lending regulations. CarePayment (CP) is one entity that provides zero interest financing to individuals from participating medical facilities. An independent, initial outcome study was undertaken to understand the demographic and medical debt-related outcomes of CP users. This information is integral to understanding whether and how this program can ameliorate the negative consequences of medical debt. METHODS: A nationwide telephone survey was conducted with a random sample of 8122 guarantors who were paying off CarePayment debt as of January 1, 2015. Respondents were asked about their demographic characteristics as well as self-report of negative outcomes typically associated with medical debt. Analyses included descriptive statistics along with logistic regression models comparing first-time CP users and those with higher amounts of CP debt to others. RESULTS: The most commonly reported financial challenge related to medical bills was problems paying or being unable to pay medical bills (59.5 %). The most commonly reported access-to-care challenges were skipping a medical test or treatment recommended by a doctor (32.9 %) and having a medical problem but not going to the doctor/clinic (30.3 %). Comparisons between first-time and repeat CP users suggest that first-time users were significantly more likely to report several negative outcomes and those with both CP and non-CP debt were significantly more likely to report nearly all of the undesirable financial and access outcomes that were assessed compared to those with only CP debt. CONCLUSIONS: The results suggest that CP use, especially repeat CP use, may be associated with a reduction in many negative outcomes of medical debt. In addition, while we found that individuals with only CP debt fared better than those with both CP debt and other medical debt, 60 % of our sample had more than one source of medical debt. This suggests that the beneficial impact of CP could be increased by expanding access to the program.

Lessons learned from a healthful vending pilot program in Delaware state agency buildings, 2011-2012.

INTRODUCTION: Changes in food availability in worksites can result in changes in eating behavior and weight status. Nemours Health and Prevention Services, in conjunction with partners in Delaware, conducted a 6-month pilot program to assess the feasibility and impact of requiring that 75% of the items in vending machines in 3 state agency buildings have healthful items. METHODS: We collected process evaluation data from October 2011 through April 2012 by taking weekly photographs of all machines to record the number of healthful items available. Outcomes were measured through sales reports designed to enumerate changes in number and type of items sold and overall profit from each building. RESULTS: We found challenges in fully implementing the 75% goal. In one of the 3 buildings, all machines were compliant within 7 weeks; in another, full compliance did not occur until week 19. Despite these challenges, the number of items sold in each machine was comparable to numbers from the previous year. Total profits from each building varied across the 3 sites and during the pilot. One building had a 51% increase in profits in January 2012 compared with profits averaged for January 2011 and January 2010. In contrast, monthly profit at another building fluctuated from an increase of 6% to a loss of 30%. CONCLUSION: Overall, our results suggest that collaborative efforts can result in a feasible intervention with little negative influence on profits.

Evaluation design of New York City's regulations on nutrition, physical activity, and screen time in early child care centers.

This article describes the multi-method cross-sectional design used to evaluate New York City Department of Health and Mental Hygiene's regulations of nutrition, physical activity, and screen time for children aged 3 years or older in licensed group child care centers. The Center Evaluation Component collected data from a stratified random sample of 176 licensed group child care centers in New York City. Compliance with the regulations was measured through a review of center records, a facility inventory, and interviews of center directors, lead teachers, and food service staff. The Classroom Evaluation Component included an observational and biometric study of a sample of approximately 1,400 children aged 3 or 4 years attending 110 child care centers and was designed to complement the center component at the classroom and child level. The study methodology detailed in this paper may aid researchers in designing policy evaluation studies that can inform other jurisdictions considering similar policies.

Measurement of compliance with New York City's regulations on beverages, physical activity, and screen time in early child care centers.

INTRODUCTION: Policy interventions designed to change the nutrition environment and increase physical activity in child care centers are becoming more common, but an understanding of the implementation of these interventions is yet to be developed. The objective of this study was to explore the extent and consistency of compliance with a policy intervention designed to promote nutrition and physical activity among licensed child care centers in New York City. METHODS: We used a multimethod cross-sectional approach and 2 independent components of data collection (Center Evaluation Component and Classroom Evaluation Component). The methods were designed to evaluate the impact of regulations on beverages served, physical activity, and screen time at child care centers. We calculated compliance scores for each evaluation component and each regulation and percentage agreement between compliance in the center and classroom components. RESULTS: Compliance with certain requirements of the beverage regulations was high and fairly consistent between components, whereas compliance with the physical activity regulation varied according to the data collection component. Compliance with the regulation on amount and content of screen time was high and consistent. CONCLUSION: Compliance with the physical activity regulation may be a more fluid, day-to-day issue, whereas compliance with the regulations on beverages and television viewing may be easier to control at the center level. Multiple indicators over multiple time points may provide a more complete picture of compliance - especially in the assessment of compliance with physical activity policies.

Chronic Disease Risk of Family Child Care Professionals:: Results of a Statewide Survey of Health and Wellbeing Indicators.

Objective: To document the chronic disease risk factors and prevalence rate of family child care professionals. Given that a significant number of young children spend time in family child care (FCC) settings, these environments are an important focus for efforts to improve children's health. Methods: Data were collected in fall 2021 from a statewide survey of licensed FCC professionals in one mid-Atlantic state (N=541), using validated questionnaires to assess health status, including chronic diseases like high blood pressure, diabetes, and asthma, as well as nutrition and physical activity. Results: While a majority of respondents reported good overall health and adherence to healthy behaviors like drinking water, eating fruits and vegetables, and engaging in physical activity, a substantial proportion were overweight or have obesity (86.1%), and there were notable rates of high blood pressure (41.1%) and asthma (17.9%). The study found higher diabetes rates among FCC professionals compared to national averages for early childhood education workers, possibly reflecting demographic differences. Conclusions: The results highlight both areas needing support, such as managing chronic disease risks, and areas where FCC professionals excel, like maintaining healthy lifestyle habits. Policy Implications: There is a need for targeted support for FCC professionals to manage and prevent chronic diseases, thereby ensuring their wellbeing and enabling them to continue being positive health role models for the children in their care.

Illuminating Child and Adult Care Food Program Partnerships That Improved Food Access and Waiver Utilization for Feeding Young Children in Early Care and Education Programs During COVID-19: A Qualitative Study.

BACKGROUND: Little is known about the partnerships formed between early care and education (ECE) programs and the Child and Adult Care Food Program (CACFP) and other organizations to continue to feed young children during the COVID-19 pandemic. Such information can provide important lessons to build ECE capacity for feeding children during future emergencies and has the potential strengthen the ECE food systems. OBJECTIVE: This study aimed to identify the unique partnerships that CACFP state agencies established to provide nutrition to young children during the COVID-19 pandemic DESIGN: Qualitative semi-structured interviews with 24 participants representing 21 states across the United States. PARTICIPANTS/SETTING: Virtual interviews with CACFP directors from December 2020 through May 2021. ANALYSIS: Following the realist method, transcripts were analyzed using thematic analysis. Codes were developed inductively and grouped to identify themes and subthemes. RESULTS: Four themes were identified: (1) CACFP partnerships that supported children and families directly; (2) CACFP partnerships that built the capacity of ECE providers to provide food to children in their own settings; (3) CACFP systems-level partnerships that improved coordination of efforts to continue to feed children in ECE; and (4) CACFP directors encouraged other CACFP state agencies to build nontraditional, diverse partnerships that can be leveraged during pandemics and other natural disasters. Within these themes (subthemes), the purpose of the partnerships focused on improving waiver utilization (eg, Department of Transportation, state health departments), improving food access (eg, Summer Food Service Program [SFSP], food banks, grocery stores, dairy councils), supporting ECE programs to participate in food reimbursement programs (eg, SFSP, CACFP sponsors), and resource sharing (eg, coalitions, CACFP sponsors). CONCLUSIONS: The CACFP state directors reported that existing and new partnerships between CACFP state agencies and external entities successfully facilitated feeding young children in ECE during the COVID-19 pandemic. States may consider developing a road map to proactively explore potential partners in their state to meet specific needs such as accessibility, availability, and affordability for feeding young children in ECE.

Family child care providers' compliance with state physical activity regulations, Delaware Child Care Provider Survey, 2011.

INTRODUCTION: Delaware is one state that has implemented comprehensive child care regulations to foster healthy dietary and physical activity behaviors of young children. This study describes the Delaware family child care environment and providers' knowledge of and compliance with physical activity regulations. We analyzed the data to determine characteristics associated with predictors of knowledge of and compliance with these regulations. METHODS: A random stratified sample of 663 licensed Delaware family child care providers was mailed a survey on family child care characteristics and providers' awareness and practices of the child care regulations. Three logistic regression models were used to explore the association between provider characteristics and their knowledge of and compliance with the regulations. RESULTS: Ultimately, 313 of the 663 eligible family child care providers participated in the survey (47.2% response rate). Controlling for covariates, we found that family child care providers' education level was significantly associated with knowledge of the physical activity regulation. Another model showed that family child care providers with larger amounts of outdoor space were more likely to report compliance with the recommendation for unstructured physical activity than those without this described space (odds ratio, 2.45). A third model showed a significant association between available indoor space for all activities including running and reported greater compliance with the recommendation for structured physical activity than was reported by caregivers with less indoor space (odds ratio, 11.2). CONCLUSION: To provide the recommended levels of physical activity for children in child care, the available physical space environment is an important area of focus for advocates of physical activity recommendations within the family child care environment.

COVID-19 Vaccination Status and Attitudes of Family Child Care Providers in Delaware, September 2021.

Child care providers, including family child care (FCC) providers, are viewed as trusted sources of information for the parents and families they serve, and their vaccine behavior has been shown to be associated with parent beliefs and behaviors. This study sought to describe the COVID-19 vaccine behaviors and attitudes among FCC providers in Delaware. An online survey was distributed to all licensed FCC providers (N = 541) in September 2021. Survey items were drawn from validated instruments and assessed vaccination status, attitudes, and confidence in their ability to discuss COVID-19 vaccines with families. In total, 168 responses were recorded (31% response rate); 69.8% of respondents were fully vaccinated against COVID-19. The majority indicated that they would require (11.4%) or recommend (42.1%) the vaccine for children in their care, once approved by the FDA. Providers reported high levels of confidence in their ability to discuss both the benefits and risks of COVID-19 vaccines. FCC providers should be considered key messengers for the families they serve and may be helpful liaisons with state and local vaccination efforts. Input from FCC providers could be used to develop vaccine messaging and materials that are clear, consistent, and culturally responsive to the families of the children in their care.

Shining the Light on You:: An Evidence-Based Program Designed to Improve the Health and Wellbeing of Family Child Care Professionals.

Objective: To design and assess the effectiveness of an evidence-based intervention to improve the health and wellbeing of family child care professionals. Methods: The early care and education (ECE) workforce, and family child care (FCC) educators in particular, face challenges to their wellbeing, mental and physical health. In addition, the demographics of the FCC workforce - disproportionately composed of low-income women of color - are associated with higher risk for chronic diseases. The Shining the Light on You program is designed to address FCC professional wellbeing in a feasible, evidence-based manner. The program includes weekly virtual sessions co-facilitated by a Board-Certified Health and Wellness Coach (HWC) and a Technical Assistance Coach (Early Childhood Specialist) and three individual coaching sessions with the HWC. HWC is built upon a foundation of behavior change theories, motivational strategies and effective communication approaches from psychology, medicine, public health and related fields. Using a mixed methods approach to gather data, participants from three initial cohorts of the program (n=33) implemented in Delaware reported improvement in health and wellbeing indicators. Results: Participants reported improvements in social support, physical activity and water consumption from pre- to post-program surveys. In interviews conducted with the participants following the program, participants consistently commented on the connections between all components of wellbeing and the importance of self-care. Conclusions: This model demonstrates the potential of integrating best practices from HWC and the ECE system.

Implementation of Federal Waivers for Feeding Children in Early Care and Education During the COVID-19 Pandemic.

OBJECTIVE: To capture Child and Adult Care Food Program (CACFP) state directors' experiences implementing federal waivers for feeding children in early care and education (ECE) settings during coronavirus disease 2019. DESIGN: Qualitative semistructured interviews. SETTING: Virtual interviews with state CACFP directors. PARTICIPANTS: Child and Adult Care Food Program directors from 21 states from December 2020 to May 2021. PHENOMENON OF INTEREST: Implementation of state-level waivers. ANALYSIS: Qualitative thematic analysis. RESULTS: State directors reported that the coronavirus disease 2019 waivers allowed ECE programs to continue feeding children despite being closed or having limited enrollment. The meal pattern, noncongregate feeding, parent/guardian meal pick-up, and monitoring waivers were most frequently used by states. Challenges included maintaining integrity to CACFP meal pattern requirements, addressing the limited capacity of ECE to produce and distribute noncongregate meals, and adapting technology for virtual reviews. Suggested improvements included streamlined communication from the US Department of Agriculture, standing waivers for emergencies, ongoing flexibilities for feeding children, and strategies to increase CACFP enrollment and reduce financial viability requirements for ECE. CONCLUSIONS AND IMPLICATIONS: Results indicate the need for the US Department of Agriculture to consider issuing and extending waivers, increasing ECE participation in CACFP, and ensuring timely communication and guidance on waiver tracking.

College student reactions to smoking bans in public, on campus and at home.

We examined college student reactions to a statewide public smoke-free policy, campus policies and private restrictions through an online survey among 2260 students at a 2-year college and a university and 12 focus groups among smokers. Among survey participants, 34.6% smoked in the past month (35.0% daily, 65.0% non-daily). Correlates of receptivity to public policies included attending the university, not living with smokers and non-smoker status (versus daily and non-daily smoking). Correlates of receptivity to outdoor campus policies included being a university student, unmarried, without children, from homes where parents banned indoor smoking and a non-smoker. Correlates of having home restrictions included not living with smokers, no children, parents banning indoor smoking and non-smoker status. Correlates of having car restrictions included attending the university, not living with smokers, having children, parents banning indoor smoking and non-smoker status. Qualitative findings indicated support for smoke-free policies in public (albeit greater support for those in restaurants versus bars) and on campus. Participants reported concern about smokers' and bar/restaurant owners' rights, while acknowledging several benefits. Overall, 2-year college students and smokers (non-daily and daily) were less supportive of smoke-free policies.

Collaborative Assessment Of Collective Reach And Impact Among INBRE Supported Summer Undergraduate Research Programs Across The United States.

The motivational outcome of undergraduate research experiences is an increasingly common component of STEM education practices. Student benefits associated with these experiences include increased interest and retention in STEM and/or research fields. Across the country, many institutional research activities in twenty-three states and Puerto Rico are supported through the National Institutes of Health's Institutional Development Award (IDeA) Networks of Biomedical Research Excellence (INBRE) Program. INBREs are statewide collaborations of research intensive and primarily undergraduate institutions that are designed to support the biomedical research pipeline as well as faculty research. Most INBREs offer summer undergraduate research experiences to meet their program goals. While the structure and focus of these programs are tailored to state-specific needs, they typically include 10-15 week sessions and many emphasize participation from underrepresented student populations. In summer 2019, eleven INBREs collaborated to explore the collective reach and impact of their summer undergraduate research programs (SURPs). A common set of survey items were identified and added to pre- and/or post-program surveys. These items focused on the reach of the programs (e.g. demographics of participating students) and the impact of the programs on educational goals for students. In total, data from 461 students across 11 states were included in the project. One third of participating students were from underrepresented racial/ethnic groups; 28% were first-generation college students and 34% were Pell grant eligible. After the program, 72% of participants reported that they hoped to earn a doctoral-level degree. Our results suggest that INBRE-supported SURPs are successfully reaching underrepresented students and that INBRE-supported students widely anticipate pursuing graduate level study in STEM fields.

Defining "smoker": college student attitudes and related smoking characteristics.

INTRODUCTION: Less than half of college students who have smoked in the past month identify themselves as smokers. Thus, we examined (a) how college students define the term "smoker" and (b) how this definition impacts smoking behavior and attitudes. METHODS: We conducted 12 focus groups with a total of 73 college student smokers drawn from survey participants at two colleges in Minnesota (a two-year technical college and a four-year university). Each group was homogenous in terms of gender and school (two-year, four-year). RESULTS: The majority (56.2%) were female, 49.3% attended a 2-year college, and 32.9% were regular smokers (smoked > or = 25 of the last 30 days). Participants described a "smoker" in terms of (a) smoking frequency, ranging from smoking infrequently to smoking daily; (b) contextual factors, such that smoking alone indicates being a smoker rather than smoking at parties; (c) time since initiation; (d) whether one purchases cigarettes, such that "smokers" buy cigarettes while nonsmokers borrow them; (e) addiction and being able to quit without great effort; (f) whether smoking is habitual; and (g) personality and physical characteristic. These beliefs had implications on experiences in quitting smoking, motivation to quit, and perceived barriers. Many participants indicated confidence in being able to quit but believed that they were not "smokers" and thus did not need to quit. DISCUSSION: College students use a broad range of criteria to define who is a smoker. These criteria impact how motivated students are to quit smoking and their perception of needing to "quit smoking."

Implementation of Revised Nutrition Standards in US Department of Agriculture's Child and Adult Care Food Program.

OBJECTIVE: In October 2017, substantial changes were made to improve the nutritional quality of meals served in the Child and Adult Care Food Program (CACFP). This study describes the experience of child care providers and sponsors during the first year of implementation. METHODS: A 1-time survey was administered to CACFP sponsors in Delaware 1 year after implementation of the changes. Data analysis included frequencies and chi-square tests of independence. RESULTS: Among respondents (n = 137), 21% faced moderate or significant challenges. Food cost (53.1%) and communicating with parents about changes (44.6%) were the most common challenges faced. The majority reported that parents supported the changes and that children and teachers generally ate the new food. CONCLUSIONS AND IMPLICATIONS: A minority of providers in Delaware faced significant challenges, suggesting that broad changes to CACFP may be feasibly implemented across settings. Training focused on food cost and parent communication may be warranted.

The health status of the early care and education workforce in the USA: a scoping review of the evidence and current practice.

BACKGROUND: More than two million early care and education (ECE) providers care for young children in the USA each day. These providers tend to earn low wages and many are enrolled in public assistance programs. Nearly all ECE providers are female and they are disproportionately women of color. Despite the fact that these attributes place the ECE workforce at greater risk of chronic disease, the health status of the workforce is not established and the availability and effectiveness of interventions to improve their health status is also not known. METHODS: We conducted a scoping review of both the published literature and current practice to identify all articles and interventions targeting the health status of the ECE workforce. Our search strategy identified scientific articles published in English within the past 10 years as well as any interventions targeting the ECE workforce that have been implemented within the past 3 years. Data from both scientific articles and practice were extracted using systematic methods and summarized. RESULTS: Thirteen studies described some component of physical health including diet quality (11 studies), physical activity (8 studies), and height/weight/body mass index (7 studies), and 21 studies assessed component(s) of mental health including depression (15 studies), stress (8 studies), and mindfulness (3 studies). ECE providers reported a high prevalence of overweight, obesity, and chronic disease diagnoses and spend significant time being sedentary, and some report low diet quality. Mental health concerns in this population include depression and high stress. Eleven interventions targeting ECE workforce wellness were also identified; most focused on nutrition, physical activity and/or stress. CONCLUSION: The limited evidence available for review describes a workforce in need of health promotion interventions to address high levels of mental and physical health challenges, some above and beyond peers with comparable demographic characteristics. Several promising interventions were identified from both the published and unpublished literature; these interventions should be further implemented and evaluated to assess their impact on the workforce.

Healthy default beverage policies for kids' meals: A statewide baseline assessment of restaurant managers' perceptions and knowledge in Delaware.

The consumption of sugar-sweetened beverages (SSBs) has been linked to obesity, diabetes, and other negative health outcomes among children. In response, many government entities have enacted healthy default beverage policies that require restaurants offering bundled kids' meals-food and drink items combined and sold as a single unit-to include only healthier drinks. Despite growing interest in these policies, little is known about their potential reach, restaurant management perceptions, and possible implementation challenges. This study evaluated restaurant managers' knowledge and support of a policy in Delaware that had passed, but not yet gone into effect. We conducted structured in-person interviews with managers (n = 50) from full-service and quick-service chain and non-chain restaurants (QSRs) using a stratified random sample. Managers were interviewed about the number of bundled meals sold, beverage sales with those meals, and awareness and perceptions of the policy. On average, QSRs sold significantly more bundled kids' meals per week (281) compared to full-service restaurants (111), and managers from chain restaurants reported selling significantly more bundled kids' meals per week (233) compared to non-chain restaurants (91). Managers reported 72.5% of those meals were sold with a healthier beverage (water, milk, or 100% juice), consistent with the forthcoming policy, while 28% were sold with SSBs. Furthermore, although only three managers (6%) reported knowing about the policy, the majority supported it when it was explained. Our findings indicate general support for the intent of the policy, but suggest the need for tailored implementation approaches and additional education for restaurant manager's and staff.