Child And Adult Care Food Program Research Articles

Child and Adult Care Food Program: Family Childcare Home Providers’ Perceptions of Impacts of Increased Meal and Snack Reimbursement Rates during the COVID-19 Pandemic

Introduction: The U.S. Child and Adult Care Food Program (CACFP) provides tiered reimbursements for healthy foods for children at participating family childcare homes (FCCH). Higher tier 1 reimbursements are for providers who operate in low-income communities or who are themselves living on a low income. All FCCHs received a higher rate to address food insecurity during the COVID-19 pandemic. Methods: A survey was administered in the spring of 2023 to a randomly selected sample of licensed California FCCHs to assess the perceived impacts of the increased reimbursement on CACFP participation and anticipated challenges with reinstated tiered rates. A total of 518 surveys (261 tier 1, 257 tier 2) were analyzed using linear or logistic regression, adjusting for confounders. Results: Among tier 1 and tier 2 providers combined, over half reported lowering out-of-pocket spending for food (59%) and serving greater variety (55%) and quality (54%) of foods. Tier 2 providers reported experiencing more benefits (p < 0.05) and tended to be more likely to implement optional CACFP best practices (although not significantly different between tiers). Most FCCH providers found reimbursement rates were inadequate before (83%) the pandemic; this amount decreased to 54% post-pandemic for tier 1 and tier 2 providers combined. Conclusions: The temporary CACFP reimbursement positively impacted the perceived quality and variety of foods served to children, especially among tier 2 providers. Increased reimbursements for all FCCHs may ensure children have access to the healthy meals and snacks provided by the CACFP.

Influence of Meals and Snacks Provided Through the Child and Adult Care Food Program (CACFP) on Young Children’s Total Dietary Intake

Influence of Meals and Snacks Provided Through the Child and Adult Care Food Program (CACFP) on Young Children’s Total Dietary Intake

Change in Nutrition and Physical Activity Practices in Early Childcare and Education Settings in Illinois During the COVID-19 Pandemic.

For many young children, early childcare and education (ECE) programs are the only source of nutritious meals and physical activity (PA); however, the COVID-19 pandemic led to program closures, restrictions, and changed practices. To examine changes in nutrition and PA-related best practices in ECE settings in Illinois from 2019, just prior to the pandemic, as compared to 2022. We also examined how changes over time varied by program type (ie, centers vs homes), Child and Adult Care Food Program (CACFP) status, and/or Head Start/Early Head Start status. The study design is a repeated cross-sectional survey administered in December 2019 and October 2022. State of Illinois. A total of 888 and 1162 ECE providers completed initial and follow-up surveys, respectively. NA. Provider report of meeting 14 nutrition and 9 PA-related best practices. Overall, 9 nutrition-related best practices were maintained and 5 declined over time. Centers, CACFP, and Head Start providers reported significant declines in meeting nutrition-related practices over time. A total of 8 PA-related best practices were maintained and 1 declined over time. Centers reported a significant decline in 5 of the PA-related best practices over time, and these declines were significantly different than in homes over time. Similarly, Head Start programs reported a decline in 4 PA-related best practices over time, and the change was significantly different from non-Head Start programs in 3 of the 4 practices. The findings of this study should be considered a new baseline for ECE nutrition and PA-related best practices in Illinois and should serve as a wake-up call for advocates nationwide with regard to the provision of nutrition and PA-related best practices in centers and by CACFP and Head Start providers postpandemic.

Evaluation of an Online Training Course for Childcare Providers Participating in the CACFP Infant Feeding Program.

The Child and Adult Care Food Program (CACFP) provides reimbursement for meals and snacks offered in participating centers and issues nutrition standards, including guidelines for feeding infants in childcare settings. Offering training to childcare providers participating in the CACFP is necessary to ensure compliance with nutrition standards in childcare settings. A State Department of Education and University Extension system collaborated to develop an online nutrition training course for childcare providers. Providers (n = 57) participated in the course on CACFP nutrition standards related to feeding infants (0-12months of age). Thirty-two of 57 participants completed both pre- and post-training surveys that were used to assess changes in knowledge and confidence concerning infant feeding standards. Paired t-tests and Wilcoxon signed-rank tests were conducted to assess differences in survey responses before and after the course. Self-confidence and knowledge of providers related to infant feeding were significantly increased after completion of the training course (p < 0.001). More participants reported their sites were likely to respond to infants showing they were hungry or full than before the course (44.4% vs. 75.7%, respectively). Participant feedback indicated the online asynchronous course was convenient, useful, and topics were relevant to training needs. The online course was feasible and effective for providing training on CACFP guidelines for childcare providers. Feedback from participants can be adapted and used for future training programs to further improve the course and delivery methods and efficiently reach a broad audience of childcare providers.

Opportunities to Improve Access to and Retention in the Child and Adult Care Food Program: Key Recommendations From Early Childcare Providers in Illinois, December 2020-July 2021.

Objectives. To identify recommendations to improve access to and retention in the Child and Adult Care Food Program (CACFP) as critical strategies to address health equity for low-income children. Methods. We conducted a qualitative key informant study of early childcare center and home providers (n = 35) in low-income urban and rural census tracts in Illinois between December 2020 and July 2021. Interviews with providers were organized and analyzed by the study team in MAXQDA Qualitative Data Analysis software. Themes were refined and finalized via member checking with an expert panel of providers and advocates. Results. Overall, providers spoke positively of the benefits of CACFP participation. Themes that centered around strategies to improve awareness of and access to CACFP included (1) conducting systematic statewide outreach, (2) improving technical assistance for enrollment, and (3) supporting positive sponsor-provider relationships. Themes related to retention included (1) alleviating procurement burdens, (2) extending reimbursement rates, and (3) expanding flexibilities. Conclusions. Policymakers looking to increase access to and retention in CACFP could consider state-level strategies such as systematic outreach and more targeted technical assistance. (Am J Public Health. 2024;113(S3):S231-S239. https://doi.org/10.2105/AJPH.2023.307433).

Perspectives of Home-Based Child Care Providers in New Mexico on Barriers and Facilitators to Participating in the Child and Adult Care Food Program, 2021-2022.

This study examined New Mexico home-based child care provider perspectives (n = 75) on barriers to and facilitators of Child and Adult Care Food Program (CACFP) participation. Two thirds of the sample were Spanish speakers. Providers reported that CACFP reimbursement does not cover actual food costs and the time-and-effort costs of obtaining qualifying foods and completing required documentation. They noted that additional reimbursed meals are needed for children in care for extended hours and that linguistically competent CACFP sponsor staff facilitated their participation. (Am J Public Health. 2023;113(S3):S215-S219. https://doi.org/10.2105/AJPH.2023.307402).

State Regulations Set the Stage for Child and Adult Care Food Program (CACFP) Participation in Home-Based Childcare.

State Regulations Set the Stage for Child and Adult Care Food Program (CACFP) Participation in Home-Based Childcare.

State Agency Perspectives on Successes and Challenges of Administering the Child and Adult Care Food Program

The federal Child and Adult Care Food Program (CACFP) improves nutrition and reduces food insecurity for young children while helping cover food costs for care providers and families. Despite its important benefits, the program is underutilized. This report uses qualitative interviews with state CACFP administrators representing 28 states to explore federal and state policies and practices that support or discourage CACFP participation among licensed child care centers. We report on successful approaches to program outreach and administration, barriers that make CACFP participation challenging, and recommendations to expand access to CACFP for eligible child care providers and the populations they serve.

How policy implementation shapes the impact of U.S. food assistance policies: the case study of the Child and Adult Care Food Program.

Much of the chronic disease burden in the U.S. population can be traced to poor diet. There has been a sustained focus on influencing children's diets and encouraging healthier eating habits by changing policies for what foods and beverages can be served to children through large federally-funded nutrition assistance programs. Yet without attention to how nutrition policies are implemented, and the surrounding context for these policies, these policy changes may not have the intended results. In this perspective, we used Bullock et al.'s (2021) Process Model of Implementation from a Policy Perspective to analyze how the complexities of the implementation process of large-scale nutrition policies can dilute potential health outcomes. We examine the Child and Adult Care Food Program (CACFP), a federal program focused on supporting the provision of nutritious meals to over 4 million children attending childcare, as a case study. We examine how the larger societal contexts of food insecurity, attitudes towards the social safety net, and a fragmented childcare system interact with CACFP. We review the "policy package" of CACFP itself, in terms of its regulatory requirements, and the various federal, state, and local implementation agencies that shape CACFP's on-the-ground implementation. We then review the evidence for how each component of the CACFP policy implementation process impacts uptake, costs, feasibility, equity, and effectiveness at improving children's nutrition. Our case study demonstrates how public health researchers and practitioners must consider the complexities of policy implementation processes to ensure effective implementation of nutrition policies intended to improve population health.

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

BackgroundLittle 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. ObjectiveThis study aimed to identify the unique partnerships that CACFP state agencies established to provide nutrition to young children during the COVID-19 pandemic DesignQualitative semi-structured interviews with 24 participants representing 21 states across the United States. Participants/SettingVirtual interviews with CACFP directors from December 2020 through May 2021. AnalysisFollowing the realist method, transcripts were analyzed using thematic analysis. Codes were developed inductively and grouped to identify themes and subthemes. ResultsFour 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). ConclusionsThe 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.

Federal Nutrition Assistance for Young Children: Underutilized and Unequally Accessed

The federal Child and Adult Care Food Program (CACFP) improves nutrition and reduces food insecurity among young children by helping cover the food costs for child care providers and families. This nationwide study evaluated the extent and predictors of the CACFP's utilization among licensed child care centers to identify opportunities for expanding CACFP nutrition support. Administrative data from the CACFP and child care licensing agencies in 47 states and District of Columbia were compiled and geocoded for 93,227 licensed child care centers. CACFP participation was predicted using a multivariable Bayesian spatial logistic regression model in the sample of low-income areas to target CACFP eligible child care centers. Data were collected in 2020-2021 and analyzed in 2022. Of all licensed child care centers, 36.5% participated in the CACFP, ranging from 15.2% to 65.3% across states; when restricted to low-income areas, 57.5% participated (range, 15.7%-85.7%). Income differences did not explain the large variation in CACFP participation rates across states. Having at least three CACFP sponsoring agencies per state predicted a 38% higher probability of CACFP participation (OR=1.38; 95% Credible Interval=1.08-1.78). Currently CACFP participation rates among licensed child care centers point to program underutilization and unequal access, particularly in some states and regions. Work at the federal and state levels is warranted to expand participation in the program, above all in low-income areas, so that more young children could eat healthfully with the CACFP.

"It Has a Lot to Do With the Cumbersome Paperwork": Barriers and Facilitators of Center-Based Early Care and Education Program Participation in the Child and Adult Care Food Program.

The Child and Adult Care Food Program (CACFP) is a federally regulated feeding program that reimburses early care and education (ECE) programs for providing nutritious meals to low-income children. Participation in CACFP is voluntary and varies widely across states. This study assessed barriers and facilitators of center-based ECE program participation in CACFP and identified potential strategies to promote the participation of eligible programs. This was a multimethod (eg, interviews, surveys, and document reviews) descriptive study. Participants included stakeholders from 22 national and state agencies that work with ECE programs to promote CACFP, nutrition, and quality care; representatives of 17 sponsor organizations; and 140 center-based ECE program directors from Arizona, North Carolina, New York, and Texas. Barriers, facilitators, and recommended strategies to promote CACFP that emerged from interviews were summarized with relevant illustrative quotes. Survey data were analyzed descriptively using frequencies and percentages. Key barriers to center-based ECE program participation in CACFP shared by participants included the cumbersome CACFP paperwork, difficulty meeting eligibility requirements, strict meal patterns, difficulties with meal counts, penalties for noncompliance, low reimbursements, inadequate ECE staff to assist with paperwork, and limited trainings. Facilitators to participation included supports provided by stakeholders and sponsors through outreach, technical assistance, and nutrition education. Potential strategies recommended to promote CACFP participation would require policy change (eg, streamlining paperwork, modifying eligibility requirements, and leniency toward noncompliance) and systems-level change (eg, more outreach and technical assistance) by stakeholders and sponsor organizations. Stakeholder agencies recognized the need to prioritize CACFP participation and highlighted ongoing efforts. Policy changes are needed at the national and state levels to address barriers and ensure consistent CACFP practices among stakeholders, sponsors, and ECE programs.

The Impact of Sodium Reduction on Overall Nutrient Content in Child and Adult Care Food Program Meals.

To understand the impact of sodium reduction on the nutrient content of Child and Adult Care Food Program (CACFP) meals served through At-Risk Afterschool Meals (ARASM) without compromising the nutritional quality of the meals served. Sodium Reduction in Communities Program (SRCP) partnered with a CACFP ARASM program from October 2016 to September 2021. We assessed changes in Healthy Eating Index 2015 (HEI-2015) food component scores and macro-and micronutrients using cross-sectional nutrient analyses of October 2016 and 2020 menus. ARASM program sites in Indianapolis, IN, USA. October 2016 and 2020 menus from one CACFP ARASM program.Intervention: Sodium reduction strategies included implementing food service guidelines, modifying meal components, changing procurement practices, and facilitating environmental changes to promote lower sodium items. From baseline in 2016 to 2020, 15 meal components were impacted by the intervention which impacted 17 (85%) meals included in the analysis. Average sodium per meal reduced significantly between 2016 (837.9 mg) and 2020 (627.9 mg) (p=0.002). Between 2016 and 2020, there were significant increases in whole grains (p=0.003) and total vegetables (p<0.001) and significant reductions in refined grains (p=0.001) and sodium (p=0.02), all per 1,000 calories served. This study demonstrates that sodium content can be reduced in CACFP meals without compromising the nutritional quality of meals served. Future studies are needed to identify feasible best practices and policies to reduce sodium content in the CACFP meal pattern.

Comparison of foods and beverages served and consumed in Child and Adult Care Food Program-participating childcare centres to national guidelines.

The federal Child and Adult Care Food Program (CACFP) sets minimum nutrition and portion size standards for meals served in participating childcare programs. CACFP has been associated with more nutritious meals served. It is unclear, however, whether CACFP results in children's dietary intake being aligned with national recommendations. We assess whether children's dietary intake in CACFP-participating childcare centres meets benchmarks set by the Dietary Guidelines for Americans (DGA). This is a cross-sectional study. We used direct observation to estimate quantities of foods/beverages served and consumed per child. Mean amounts served per child per day were compared with CACFP portion size requirements for each component (fruits, vegetables, milk and meat/meat alternate). Mean amounts of foods/beverages consumed were compared with DGA recommendations (energy content, fruits, vegetables, whole/refined grains, dairy, protein and added sugars). One sample t-tests evaluated if quantities served and consumed were different from CACFP and DGA standards, respectively. Six CACFP-participating childcare centres. 2-5 year-old children attending childcare. We observed forty-six children across 166 child meals. Most meals served met CACFP nutrition standards. Compared with CACFP portion size standards, children were served more grains at breakfast and lunch; more fruits/vegetables at lunch but less at breakfast and snack and less dairy at all eating occasions. Compared with DGA recommendations, children under-consumed every food/beverage category except grains during at least one eating occasion. Children were served quantities of foods/beverages mostly consistent with CACFP portion size requirements, but had sub-optimal intake relative to DGA. More research is needed to help children consume healthy diets in childcare.

The Child and Adult Care Food Program and young children's health: a systematic review.

The Child and Adult Care Food Program (CACFP) is a federal nutrition program that supports young children's nutrition. Its potential impacts on child well-being have not been summarized. The objective of this review was to summarize the evidence for the impact of CACFP on children's diet quality, weight status, food insecurity, and cognitive development. Databases searched included MEDLINE, CAB Abstracts, Web of Science Core Collection, ERIC, PsycInfo, Dissertations & Theses Global (Proquest), EconLit, NBER, and the USDA's Economic Research Service (ERS), from database inception to November 12, 2021. Studies were included if the sample drew from child care programs serving children between the ages of 2years and 18years and if a comparison group of nonparticipating programs was included. Two reviewers independently extracted data on study design, year(s) of data collection, region, sample size, participant demographics, outcomes, and risk of bias. Due to the heterogeneity of the studies, a narrative synthesis was used. Nineteen articles were reviewed, most of which had been published since 2012. Seventeen used cross-sectional designs. Twelve evaluated foods and beverages served; 4 evaluated dietary intake; 4 evaluated the child care nutrition environment; 2 evaluated food insecurity, 1 evaluated weight status; none evaluated cognitive outcomes. Studies typically found either a small beneficial association with CACFP or no significant association. Currently, evidence for an association between CACFP and children's health is inconclusive, though it is slightly suggestive of a benefit for some dietary quality outcomes. More research, with stronger study designs, is needed. A protocol for this systematic review was registered with the PROSPERO systematic review protocol registry (PROSPERO 2021 CRD42021254423).

Impacts of Covid-19 School Closures on School Food Service Revenue: Analysis of Public Local Education Agencies in Maryland.

The public health policies and school closures in response to the Covid-19 pandemic have created disruptions in school meal programs. Research is needed to understand the changes in school food service revenue before and during the initial Covid-19-related school shutdowns. A longitudinal cohort study examining federal and state reimbursements as well as sales revenues for all public local education agencies (LEAs) in Maryland from school years (SY) 2018-2019 and 2019-2020 was conducted. Monthly changes in federal and state reimbursements for Child Nutrition Programs, including the National School Lunch Program (NSLP), School Breakfast Program (SBP), Summer Food Service Program (SFSP), and Child and Adult Care Food Program (CACFP) were examined. In the SY 2018-2019, the total revenues from federal and state reimbursements for SBP, NSLP, SFSP, and at-risk CACFP were $272.9million; in comparison, for the SY 2019-2020, the total revenues were $241.8million (11.4% reduction from SY 2018-2019). On average, the school shutdown (during March to June 2020) was associated with a $450,385 (p-value < .01) reduction in federal and state reimbursements per LEA-month (41% reduction). The school shutdown during the Covid-19 pandemic was associated with a statistically significant reduction in school food service revenues across Maryland's public LEAs.

Changes in Meal and Menu Quality at Early Care and Education Programs after Training with Food Service Staff: the FRESH Study

BackgroundPrevalence of obesity in Native American (NA) children is disproportionately high, indicating a higher risk of health disparities. Many children attend early care and education (ECE) programs, presenting an opportune environment to improve meal and menu quality as the intake of healthy foods is associated with lowered risk of childhood obesity. ObjectivesWe aimed to examine the effectiveness of food service staff training on meals and menu quality across NA ECEs. MethodsFood service staff from 9 participating ECE programs attended a 3-h training focused on Child and Adult Care Food Program (CACFP) best practices, and received a tailored, best-practice menu, and healthy recipes. Meals and menus prepared across 1 wk were examined per CACFP serving size assumptions at baseline, 4 mos, 6 mos, and 12 mos for all 9 programs. Healthy Eating Index (HEI), CACFP requirements and best practices achievement, and food substitutions quality (classified into superior, equivalent, and inferior based on the nutritional quality) were calculated. A repeated measures ANOVA model was used to determine the differences across time points. ResultsThe total meal HEI score increased significantly from baseline to 4 mos (71.1 ± 2.1; 78.6 ± 5.0; P = 0.004), but did not differ from baseline to 12 mos. Menu CACFP requirements and best practices achievement did not differ across time points, although achievement with CACFP requirements was already high at baseline. Superior nutrition quality substitutions declined from baseline to 6 mos (32.4 ± 8.9; 19.5 ± 10.9; P = 0.007); however, it did not differ from baseline to 12 mos. Equivalent and inferior quality substitutions did not differ across time points. ConclusionsImplementing a best-practice menu with healthy recipes showed immediate improvements in meal quality. Although the change did not sustain, this study showed evidence of an opportunity to educate and train food service staff. Robust efforts are needed for improving both meals and menus.This trial was registered ClinicalTrials.gov as NCT03251950 (https://clinicaltrials.gov/ct2/show/NCT03251950?cond=food+resource+equity&draw=2&rank=1).

Experiences pertaining to child nutrition and care provision among early care and education stakeholders, sponsors, and center directors during the COVID-19 pandemic: A multi-method study.

This study used multiple methods (interviews, survey) to assess experiences of stakeholders, sponsors, and center-based early care and education (ECE) program directors pertaining to child nutrition (e.g., provision of nutritious foods, mealtime practices, CACFP administration/use) and the provision of child-care (i.e., day-to-day ECE operations and programming) during the COVID-19 pandemic. Participants included stakeholders from 22 national and state agencies associated with the Child and Adult Care Food Program (CACFP) who also work to promote nutrition and quality child-care, representatives of 17 CACFP sponsor organizations, and 40 center-based ECE program directors who participated in interviews, as well as 100 ECE directors who completed surveys. Data were collected across four states. Thematic analyses of interviews and descriptive methods were used to analyze data collected. Six main themes emerged from stakeholders, sponsors, and ECE program directors' focusing on: experiences during the temporary closure of several ECE programs; additional responsibilities and unanticipated expenses for ECE programs; difficulty in keeping up with constantly changing COVID-19 guidance; encounters during shifts from in-person to virtual training and monitoring; changes to nutrition practices at ECE; and the need to prioritize ECE funding. Findings highlight challenges and supports to ECE programs and could inform future efforts to enhance child-care quality and child nutrition in the U.S. during pandemic situations.

Child and Adult Care Food Program Participation Benefits, Barriers and Facilitators for Independent Child Care Centers in California.

The Child and Adult Care Food Program (CACFP) provides reimbursements for nutritious foods for children with low-income at participating child care sites in the United States. The CACFP is associated with improved child diet quality, health outcomes, and food security. However CACFP participation rates are declining. Independent child care centers make up a substantial portion of CACFP sites, yet little is known about their barriers to participation. Researcher-led focus groups and interviews were conducted in 2021-2022 with 16 CACFP-participating independent centers and 5 CACFP sponsors across California CACFP administrative regions to identify participation benefits, barriers, and facilitators. Transcripts were coded for themes using the grounded theory method. CACFP benefits include reimbursement for food, supporting communities with low incomes, and healthy food guidelines. Barriers include paperwork, administrative reviews, communication, inadequate reimbursement, staffing, nutrition standards, training needs, eligibility determination, technological challenges, and COVID-19-related staffing and supply-chain issues. Facilitators included improved communication, additional and improved training, nutrition standards and administrative review support, online forms, reduced and streamlined paperwork. Sponsored centers cited fewer barriers than un-sponsored centers, suggesting sponsors facilitate independent centers' CACFP participation. CACFP participation barriers should be reduced to better support centers and improve nutrition and food security for families with low-income.

Facilitators and barriers to family child care home participation in the U.S. Child and Adult Care Food Program (CACFP)

This paper describes facilitators, barriers, and potential strategies to promote participation in the Child and Adult Care Food Program (CACFP) by family child care homes (FCCHs). This descriptive study occurred from January-May 2022 in Arizona and New York, two states with varying levels of CACFP participation. Stakeholders from three state-level CACFP-administering agencies, representatives of six sponsor organizations, and 23 FCCH providers (70% CACFP, 30% non-CACFP) participated in interviews. Facilitators of CACFP participation included the simple enrollment, technical assistance from sponsors, software provided by sponsors, and incentives from state agencies. Barriers included perceptions that CACFP paperwork would be burdensome, lack of access to sponsors, and challenges with meal pattern requirements. Recommended strategies to promote CACFP uptake included educating providers about CACFP, expanding outreach, and additional funding. Efforts to address state-level disparities in FCCH participation in CACFP are needed. This study provides some insight into policy and systems changes that could be beneficial.