Definition Of Adherence Research Articles

Treatment adherence: A Concept Analysis Using the Walker & Avant Method.

To clarify the meaning of treatment adherence and identify its attributes, antecedents, consequences, and empirical referents. A concept analysis. Walker and Avant's method was used to analyze treatment adherence. PubMed, Web of Science, Wiley Online Library, and EBSCO databases were searched from 2013 to 2023. The PRISMA 2020 checklist was used. Seventeen studies were included in this analysis. The defining attributes were the ability to comply with the treatment, consistency in the treatment plan, communication with the healthcare provider, and willingness to treat. Antecedents included multiple medicines, lifestyle changes, illness perceptions and beliefs, and long-term treatment. The outcomes included treatment success, improved long-term treatment, and improved clinical outcomes. Treatment adherence is a positive reaction of a patient to have the ability to comply with the treatment, consistency in the treatment plan, communication with the healthcare provider, and willingness to treat. This study proposes a detailed definition, attributes, antecedents, consequences, and empirical referents for treatment adherence. It is instructive to clinical nursing of treatment adherence, can be extended to various diseases, helps to improve clinical nursing practice regarding treatment adherence, and contribute to improving human health.

우울증 외래 신환 환자에서 항우울제 복약순응도에 영향을 미치는 요인 - 건강보험 직장가입자와 지역가입자를 중심으로

Objectives: Continuing to take antidepressants is very important in treating depression; however, low adherence of antidepressants is commonly seen in the treatment of depression. The purpose of this study was to investigate factors affecting adherence of antidepressants in outpatients with new onset depression. Methods: This was a retrospective cohort study using National Health Insurance claim data for services provided in 2012. We examined data from a total of 142,336 individuals aged 18 years or older who were continuously enrolled in treatment after a new episode of major depression and who had initiated antidepressant treatment. we estimated adjusted odds ratios and 95% confidence intervals using logistic regression analysis. Results: The operational definition of adherence to antidepressant treatment was medication being dispensed to the patient at least 80% of the time during 3 months (ie. MPR≥80%). A statistically significant association was found between adherence of antidepressant and gender, income level, age at first onset of depression, first antidepressants type, treatment type, first health care institution. Conclusions: Depression can lead to serious social problems such as suicide if left untreated. Therefore, it is necessary to continue research on factors influencing adherence of antidepressants.

Variation in secondary prevention of coronary heart disease: the INTERASPIRE study.

INTERASPIRE is an international study of coronary heart disease (CHD) patients, designed to measure if guideline standards for secondary prevention and cardiac rehabilitation are being achieved in a timely manner. Between 2020 and 2023, adults hospitalized in the preceding 6-24 months with incident or recurrent CHD were sampled in 14 countries from all 6 World Health Organization regions and invited for a standardized interview and examination. Direct age and sex standardization was used for country-level prevalence estimation. Overall, 4548 (21.1% female) CHD patients were interviewed a median of 1.05 (interquartile range .76-1.45) years after index hospitalization. Among all participants, 24.6% were obese (40.7% centrally). Only 38.6% achieved a blood pressure (BP) < 130/80 mmHg and 16.6% a LDL cholesterol (LDL-C) of <1.4 mmol/L. Of those smoking at hospitalization, 48% persisted at interview. Of those with known diabetes, 55.2% achieved glycated haemoglobin (HbA1c) of <7.0%. A further 9.8% had undetected diabetes and 26.9% impaired glucose tolerance. Females were less likely to achieve the targets: BP (females 36.8%, males 38.9%), LDL-C (females 12.0%, males 17.9%), and HbA1c in diabetes (females 47.7%, males 57.5%). Overall, just 9.0% (inter-country range 3.8%-20.0%) reported attending cardiac rehabilitation and 1.0% (inter-country range .0%-2.4%) achieved the study definition of optimal guideline adherence. INTERASPIRE demonstrates inadequate and heterogeneous international implementation of guideline standards for secondary prevention in the first year after CHD hospitalization, with geographic and sex disparity. Investment aimed at reducing between-country and between-individual variability in secondary prevention will promote equity in global efforts to reduce the burden of CHD.

Adherence to treatment in pulmonary tuberculosis: Rodgers' evolutionary concept analysis.

Adherence to treatment is essential for the management of pulmonary tuberculosis. Nurses and healthcare professionals play a significant role in promoting adherence behavior among this population. Nevertheless, defining adherence to treatment within this particular population remains complex. This study aimed to explore and clarify the concept of adherence to treatment among individuals with pulmonary tuberculosis. Rodgers' evolutionary concept analysis was employed in this study. A literature search was conducted in the PubMed and Scopus databases to identify relevant studies published between July 2013 and July 2023. The attributes of adherence to treatment in pulmonary tuberculosis consist of multiple components: biological, individual, social, health service, and policy-making processes. Antecedents include various patient-related factors as well as factors associated with clinical conditions and patient-health professional engagement. Three consequences of the concept have emerged: enhanced treatment efficacy, increased commitment to tuberculosis treatment adherence, and improved health service quality. This study provides a comprehensive operational definition of adherence to tuberculosis treatment, including its attributes, antecedents, and consequences. This framework will assist nurses in evaluating adherence more effectively. However, further research into the experiences of individuals adhering to tuberculosis treatment is needed to confirm and enhance these strategies.

Medication adherence and persistence in children and adolescents with attention deficit hyperactivity disorder (ADHD): a systematic review and qualitative update.

Low medication-adherence and persistence may reduce the effectiveness of ADHD-medication. This preregistered systematic review (PROSPERO CRD42020218654) on medication-adherence and persistence in children and adolescents with ADHD focuses on clinically relevant questions and extends previous reviews by including additional studies. We included a total of n = 66 studies. There was a lack of consistency in the measurement of adherence/persistence between studies. Pooling the medication possession ratios (MPR) and using the most common adherence definition (MPR ≥ 80%) indicated that only 22.9% of participants had good adherence at 12-month follow-up. Treatment persistence on medication measured by treatment duration during a 12-month follow-up averaged 170days (5.6months). Our findings indicate that medication-adherence and persistence among youth with ADHD are generally poor and have not changed in recent years. Clinicians need to be aware that various factors may contribute to poor adherence/persistence and that long-acting stimulants and psychoeducational programs may help to improve adherence/persistence. However, the evidence to whether better adherence/persistence contributes to better long-term outcomes is limited and requires further research.

An Overview of Adherence—What It Is and Why It Is Important

Asthma, allergic rhinitis, and food allergy are common allergic diseases, yet adherence to many management options remains poor, leading to worse health outcomes and financial implications for society and health systems. The underlying causes of non-adherence are numerous, ranging from patient specific factors to broader socioeconomic and systems-based factors. In this review, we aim to discuss the definition of adherence, which can be divided into 3 components: initiation, implementation, and persistence, as well as to review various methods of measuring adherence. Subsequently, we will review the epidemiology of adherence to asthma and allergic rhinitis medications, allergen immunotherapy, and oral immunotherapy. Finally, we will discuss the multifaceted etiology of poor adherence and its subsequent impact on patients and society.

A Clarification of the Concept of Clean Intermittent Catheterization Adherence Using the Evolutionary Method.

Background and Purpose: Clean intermittent catheterization (CIC) nonadherence may lead to renal compromise, incontinence, and frequent urinary tract infections in patients with spinal cord injury and spinal dysraphism. Adherence to CIC lacks definition in the nursing literature despite implications for research and clinical practice, including patient education. The aim of this concept analysis was to analyze how CIC adherence is conceptualized and synthesize a definition for nursing. Method: Rodgers' evolutionary concept analysis method was used to analyze the concept of CIC adherence in patients and caregivers. We searched databases to identify studies describing CIC adherence and identified common attributes, antecedents, and consequences. A definition was synthesized, and an exemplar was developed to illustrate the concept in practice. Results: Sixteen sources were analyzed. The attributes of CIC adherence were initiation, execution, including prescribed process and prescribed frequency, and persistence. Antecedents included the presence of neurogenic bladder, acceptance, and engagement. Consequences included improved health outcomes and quality of life. Implications for Practice: Adherence to CIC lacks definition in the nursing literature despite implications for research and clinical practice. A unified definition of CIC adherence will facilitate nurses' efforts to plan effective care, anticipate support barriers and opportunities, and develop strategies for improving CIC adherence.

Prevalence and correlates of paediatric guideline non-adherence for initial empirical care in six low and middle-income settings: a hospital-based cross-sectional study

ObjectivesThis study evaluated the prevalence and correlates of guideline non-adherence for common childhood illnesses in low-resource settings.Design and settingWe used secondary cross-sectional data from eight healthcare facilities in six Asian...

Positive airway pressure therapy adherence and outcomes in obstructive sleep apnea: An exploratory longitudinal retrospective randomized chart review.

Positive airway pressure (PAP) therapy is prescribed to patients with obstructive sleep apnea (OSA). A commonly used definition for PAP therapy adherence is based upon the minimum requirements to receive Medicare coverage in the US, defined as PAP usage of four or more hours per night on 70 percent of nights for at least 30 consecutive days. However, little evidence exists to support this definition for PAP therapy adherence. Therefore, the present study sought to determine the efficacy of the present definition of PAP therapy adherence on longitudinal outcomes in patients with OSA, using objectively measured PAP device usage time. An exploratory longitudinal, retrospective, randomized chart review was done to assess clinical outcomes between patients with OSA who were defined as PAP therapy adherent (n=50) and non-adherent (n=50) during an eight-year observation period. No significant differences were shown between groups for mortality, hospitalizations, or development of co-morbidities during the observation period. However, logistic regression showed significantly higher odds of adherence in male patients compared to female patients (OR=8.519; 95%CI=1.301-55.756; p=0.025) and significantly lower odds of adherence in patients with higher normal (OR=0.039; 95%CI=0.005-0.392; p=0.003), mild excessive (OR=0.039; 95%CI=0.003-0.517; p=0.014), and severe excessive (OR=0.088; 95%CI=0.012-0.635; p=0.016) daytime sleepiness compared to patients with lower normal daytime sleepiness. An increasing number of hospitalizations also corresponded with a significant decrease in odds of being adherent (OR=0.741; 95%CI=0.551-0.995; p=0.046). The present study supports a steadily growing body of literature calling for more consideration and evidence to support a definition of PAP therapy adherence that is clinically meaningful.

Participant Engagement and Adherence to Providing Smartwatch and Patient-Reported Outcome Data: Digital Tracking of Rheumatoid Arthritis Longitudinally (DIGITAL) Real-World Study.

Digital health studies using electronic patient-reported outcomes (ePROs) and wearables bring new challenges, including the need for participants to consistently provide trial data. This study aims to characterize the engagement, protocol adherence, and data completeness among participants with rheumatoid arthritis enrolled in the Digital Tracking of Arthritis Longitudinally (DIGITAL) study. Participants were invited to participate in this app-based study, which included a 14-day run-in and an 84-day main study. In the run-in period, data were collected via the ArthritisPower mobile app to increase app familiarity and identify the individuals who were motivated to participate. Successful completers of the run-in period were mailed a wearable smartwatch, and automated and manual prompts were sent to participants, reminding them to complete app input or regularly wear and synchronize devices, respectively, during the main study. Study coordinators monitored participant data and contacted participants via email, SMS text messaging, and phone to resolve adherence issues per a priori rules, in which consecutive spans of missing data triggered participant contact. Adherence to data collection during the main study period was defined as providing requested data for >70% of 84 days (daily ePRO, ≥80% daily smartwatch data) or at least 9 of 12 weeks (weekly ePRO). Of the 470 participants expressing initial interest, 278 (59.1%) completed the run-in period and qualified for the main study. Over the 12-week main study period, 87.4% (243/278) of participants met the definition of adherence to protocol-specified data collection for weekly ePRO, and 57.2% (159/278) did so for daily ePRO. For smartwatch data, 81.7% (227/278) of the participants adhered to the protocol-specified data collection. In total, 52.9% (147/278) of the participants met composite adherence. Compared with other digital health rheumatoid arthritis studies, a short run-in period appears useful for identifying participants likely to engage in a study that collects data via a mobile app and wearables and gives participants time to acclimate to study requirements. Automated or manual prompts (ie, "It's time to sync your smartwatch") may be necessary to optimize adherence. Adherence varies by data collection type (eg, ePRO vs smartwatch data). RR2-10.2196/14665.

Facilitators and barriers to adherence to medical recommendations among adolescents with cancer: A systematic review.

We aimed to systematically review barriers/facilitators of adherence among adolescents with cancer (aged 10-24years), following a comprehensive approach to adherence that goes beyond medication-taking. Empirical studies published in English exploring determinants of adherence to medical recommendations among adolescents with cancer were identified in MEDLINE, PsycInfo, and Web of Science, up to October 2021. Records and full-text articles were reviewed by two independent reviewers, and results were classified according to the World Health Organization's (WHO) multidimensional adherence model. Eighteen studies were included. Despite heterogeneity in the definition and measurement of adherence, literature supported barriers/facilitators at patient, treatment, condition, healthcare team/system, and social/economic levels. Specifically, patient-related factors (i.e., psychological functioning and beliefs about disease and treatment) and social-related factors (i.e., family functioning) were major determinants of adolescent adherence. Few studies were conducted, and inconsistent findings were displayed for other dimensions (i.e., healthcare team/system, treatment, and condition-related factors). Adherence is a complex and multidetermined phenomenon. More research is needed to provide critical insights for policymakers and healthcare professionals in planning practices and interventions that effectively address meaningful barriers/facilitators of adolescents' adherence.

Clinical pharmacists' perspective of medication adherence support in Ethiopian hospital settings: a qualitative study.

Hospital pharmacists can assist patients with medication adherence in a hospital setting. No studies have explored the views of hospital pharmacists on medication adherence. The study aimed to explore Ethiopian clinical pharmacists' understanding of and experience with medication adherence, and identify strategies for medication adherence support. Semi-structured interviews were conducted via ZOOM/Skype. Hospital pharmacists were recruited through a professional network and snowball sampling. All interviews were audio recorded, transcribed verbatim, translated into English and analysed using thematic analysis techniques. The data coding followed a hybrid deductive and inductive approach. Fourteen Ethiopian clinical pharmacists participated in the study. Analysis yielded five main themes including: medication adherence definition and measurement; pharmacists' perceived roles; enablers of medication adherence; barriers to medication adherence; and ways forward. Participants indicated that accurately assessing medication adherence was complicated because of an absence of cost-effective and validated tools. Pharmacist education, clinical pharmacy services, physical structure, sources of medication information, and government initiatives to reduce financial burdens were the facilitators identified. Eight barriers were identified, and these were broadly classified as factors intrinsic or extrinsic to the patient. Medication adherence support could face barriers intrinsic or extrinsic to patients. Strategies were proposed to overcome the identified barriers and to harness existing facilitators. These strategies included the need for validated local language medication adherence tools, instituting regular adherence measurement and prioritizing patients for available interventions. Patient's preferred dosage form should be considered along with medication complexity and medication knowledge when supporting medication adherence.

The complexity of patient adherence in orthopaedics: Aqualitative study to identify barriers and develop strategies for adherence partnerships.

While the importance of patient adherence to treatment protocols is firmly accepted, a definition for adherence and mechanisms to address non-adherence are not well established. The goals of this study were to define adherence and identify barriers and enablers for adherence partnerships through the lens of the orthopaedic healthcare team. The qualitative study was designed using concepts from grounded theory. Eight focus groups, comprised of orthopaedic healthcare team members, were conducted to identify factors influencing orthopaedic patient adherence to treatment plans. Healthcare team members identified a range of factors affecting patient adherence. Participants conveyed that patient non-adherence can be a deliberate decision but can also result from barriers faced by the patient. Synthesis of themes identified distinct phases of adherence and culminated in the creation of a preliminary model that encapsulates healthcare team and patient factors impacting adherence, which was entitled, The Barriers and Enablers to Treatment Adherence (BETA) Model. The study findings alleviate the patient from the sole burden of adherence, recognising the influences that the healthcare team and system have on patients' ability to adhere. The BETA model of patient adherence represents the first step to mitigating non-adherence by providing a foundation for programmatic research aimed at developing and evaluating interventions and management strategies that empower healthcare teams to effectively equip patients for adherence, leading to optimised patient outcomes following orthopaedic interventions.

Does adherence to antiretroviral therapy differ by place of residence in Nigeria? A systematic review and meta-analysis protocol

IntroductionRetention in care is still a significant challenge in the HIV treatment cascade and varies extensively across regions, leading to poor adherence to antiretroviral therapy (ART). Several factors across different...

Adherence Forecasting for Guided Internet-Delivered Cognitive Behavioral Therapy: A Minimally Data-Sensitive Approach.

Internet-delivered psychological treatments (IDPT) are seen as an effective and scalable pathway to improving the accessibility of mental healthcare. Within this context, treatment adherence is an especially pertinent challenge to address due to the reduced interaction between healthcare professionals and patients. In parallel, the increase in regulations surrounding the use of personal data, such as the General Data Protection Regulation (GDPR), makes data minimization a core consideration for real-world implementation of IDPTs. Consequently, this work proposes a Self-Attention-based deep learning approach to perform automatic adherence forecasting, while only relying on minimally sensitive login/logout-timestamp data. This approach was tested on a dataset containing 342 patients undergoing Guided Internet-delivered Cognitive Behavioral Therapy (G-ICBT) treatment. Of these 342 patients, 101 ( ∼30%) were considered non-adherent (dropout) based on the adherence definition used in this work (i.e. at least eight connections to the platform lasting more than a minute over 56 days). The proposed model achieved over 70% average balanced accuracy, after only 20 out of the 56 days ( ∼1/3) of the treatment had elapsed. This study demonstrates that automatic adherence forecasting for G-ICBT, is achievable using only minimally sensitive data, thus facilitating the implementation of such tools within real-world IDPT platforms.

Adherence to Society for Vascular Surgery Guidelines for Claudication in the Society for Vascular Surgery Vascular Quality Initiative

Current Society for Vascular Surgery (SVS) guidelines recommend 51 specific factors related to the management of intermittent claudication as quality measures. It was the objective of this study to assess rates of adherence to these guidelines for patients treated with suprainguinal or infrainguinal bypass or percutaneous vascular intervention and to determine if this was associated with a difference in the periprocedural outcomes. All patients from the SVS Vascular Quality Initiative (VQI) undergoing infrainguinal bypass (INFRA), suprainguinal bypass (SUPRA), and percutaneous vascular intervention (PVI) for claudication from 2018 were included. Nonelective procedures for other than chronic atherosclerotic disease were excluded. The rates of adherence to each assessable guideline were evaluated. For outcomes analysis, individuals were classified as “adherent” to the guidelines vs not and compared. Of the 51 SVS recommendations, 12 could be evaluated using VQI registries; these included first-line ankle-brachial index, smoking cessation, statin therapy, antiplatelet therapy with aspirin, optimal medical therapy after intervention, anatomic imaging studies before intervention, optimizing diabetes control, Plavix as second-line antiplatelet, adjunct stenting in intermediate superficial femoral artery lesions, annual follow-up, covered stents for the treatment of aortoiliac disease, and no recommended endovascular treatment for isolated infrapopliteal disease. The rates of overall “adherence” were 38.2% for INFRA, 17.1% for SUPRA, and 32.2% for PVI. There were a surprising number of isolated tibial (n = 1431, 3.1%) and pedal (n = 12, 0.03%) endovascular interventions performed for claudication. There were 784 tibial bypasses (19.3%), 30 (0.7%) at the ankle, 2 of which were tarsal/plantar bypasses for claudication. It appears that for the most part, there do not seem to be important clinical differences in outcomes based on the study definition of adherence for all outcomes assessed. Among factors such as survival (Fig 1), time to amputation (Fig 2), primary patency (Fig 3), and time to reoperation/reintervention for occlusion (Fig 4) for INFRA, SUPRA, and PVI, there were no differences between individuals meeting the study definition of adherence vs those not adherent for all outcomes was assessed. Overall adherence rates to SVS guidelines for the management of intermittent claudication are low and may be an opportunity for improvement in patient outcomes. An absence of differences noted in this study may reflect unmeasured factors in patient selection or in outcomes. Adding more of the SVS recommendations for the management of intermittent claudication to the VQI registry may serve as a future focus for quality improvement projects.

Medication Adherence and Healthcare Costs in Chronically Ill Patients Using German Claims Data.

Despite the importance of medication adherence for chronically ill patients and the vast literature on its relationship to costs, this field suffers from methodological limitations. These are caused, amongst others, by the lack of generalizability of data sources, varying definitions of adherence, costs, and model specification. We aim to address this with different modeling approaches and to contribute evidence on the research question. We extracted large cohorts of nine chronic diseases (n = 6747-402,898) from German claims data of stationary health insurances between 2012 and 2015 (t0-t3). Defined as the proportion of days covered by medication, we examined the relationship of adherence using several multiple regression models at baseline year t0 with annual total healthcare costs and four sub-categories. Models with concurrent, and differently time-lagged measurements of adherence and costs were compared. Exploratively, we applied non-linear models. Overall, we found a positive association between the proportion of days covered by medication and total costs, a weak association with outpatient costs, positive with pharmacy costs, and frequently negative with inpatient costs. There were major differences by disease and its severity but little between years, provided adherence and costs were not measured concurrently. The fit of linear models was mainly not inferior to that of non-linear models. The estimated effect on total costs differed from most other studies, which highlights concerns about generalizability, although effect estimates in sub-categories were as expected. Comparison of time lags indicates the importance of avoiding concurrent measurement. A non-linear relationship should be considered. These methodological approaches are valuable in future research on adherence and its consequences.

Methods for assessing guideline adherence for invasive procedures in the care of chronic coronary artery disease: a scoping review

ObjectivesIn the care of coronary artery disease (CAD), evidence questions the adequate application of guidelines for cardiovascular procedures, particularly coronary angiographies (CA) and myocardial revascularisation. This review aims to examine...

CORRELATION OF KNOWLEDGE AND ATTITUDE TOWARD HYPERTENSION SELF-MANAGEMENT PRACTICE DURING THE COVID-19 PANDEMIC

Introduction: Restrictions on mobility during the COVID-19 pandemic have worsened lifestyle and made it harder for people with hypertension to manage their condition, which can lead to complications. Knowledge and attitude have a significant correlation toward hypertension self-management. This study aimed to determine the correlation between knowledge and attitudes of hypertensive patients toward hypertension self-management practice during the COVID-19 pandemic.&#x0D; Method: The method used was a descriptive-analytic correlation with a cross-sectional approach. The sample used was 50 hypertensive patients aged ≥ 15 years old, samples obtained through the accidental sampling technique. Data collection through the google form online questionnaire containing a modified Indonesian version of the Knowledge, Attitudes, and Practice Level of Hypertensive Patients on Lifestyle Modification questionnaire. Statistical test for bivariate using Pearson and Spearman correlation.&#x0D; Result: The study found that 54% respondents had good knowledge and practice, and 50% had a positive attitude toward hypertension self-management during the COVID-19 pandemic. Poor hypertension self-management practices include 56% of respondents did not exercise; 54% did not plan a diet to control blood pressure; 32% did not measure blood pressure regularly; and 46% did not take antihypertensive drugs. Bivariate analysis showed that there was a correlation between knowledge (p = 0.000; r = +0.320), and attitudes (p = 0.001; r = +0.471) toward hypertension self-management practice during the COVID-19 pandemic.&#x0D; Conclusion: The study results showed that the correlation is positive, but the strength of the correlation is weak. therefore, it is necessary to educate the public regarding hypertension and self-management during the COVID-19 pandemic, especially regarding the definition of hypertension, medication adherence, and lifestyle modifications to control hypertension.&#x0D; &#x0D; Keywords: Attitude; COVID-19; Hypertension; Knowledge; Self-management

Adherence to Healthy Default Beverage Laws for Children's Meals in 3 U.S. Cities

Healthy default beverage laws are relatively new interventions designed to improve the healthfulness of children's meals in restaurants. In this study, researchers assessed adherence to healthy default beverage laws among children's meals ordered online in Los Angeles (California statewide law effective from September 2018), Baltimore (effective from April 2018), and New York City (effective from April 2019) compared with that in Boston, where no law existed. Between November and December 2020, researchers ordered children's meals from online ordering platforms (e.g., GrubHub, Uber Eats) from the top-grossing restaurant chains in each location (n=337 meal orders from 106 restaurants), coded these meals using four successively stricter definitions of adherence to the default beverage laws in each respective jurisdiction, and then applied each law to data collected in Boston to simulate different policy scenarios in a city with no such law. The team analyzed these data in late 2021. Differences in adherence existed across jurisdictions, with 15% adherent in Los Angeles, 30% in Baltimore, and 43% in New York City, compared with 7%-30% in Boston, using the most lenient definition of adherence. Fewer than 3% of all meals adhered to laws when applying the strictest definition of adherence. Overall adherence was low and variable across jurisdictions. Adherence may be lower in jurisdictions with fewer allowable default beverages, although more research is needed to assess this potential causal relation. In addition to increased resources and support for restaurants, additional policy design considerations may be necessary to increase adherence to healthy default beverage laws.