Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BackgroundAnterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.MethodsWe did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.FindingsBetween Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.InterpretationSurgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management

Using the Theory of Planned Behavior to Elicit Restaurant Employee Beliefs about Food Safety: Using Surveys Versus Focus Groups

Within the framework of the theory of planned behavior (Ajzen, 1991), this study compared the relative usefulness of utilizing a focus group or survey methodology when eliciting restaurant employees’ beliefs about performing three important food safety behaviors (handwashing, using thermometers, and cleaning and sanitizing work surfaces). Restaurant employees completed both a survey and focus group interview assessing their beliefs about food safety. Results obtained through surveys were observed to be comparable to focus groups, suggesting researchers employ the less expensive and less time-consuming survey methodology. The strengths and weaknesses of each method are discussed. Specific salient beliefs (e.g., advantages, barriers, etc.) about the behaviors offer implications for workplace food safety interventions and training

Restaurant employees' perceptions of barriers to three food safety practices

Limited research has been conducted to assess employees' perceptions of barriers to implementing food safety practices. Focus groups were conducted with two groups of restaurant employees to identify perceived barriers to implementing three food safety practices: handwashing, using thermometers, and cleaning work surfaces. Ten focus groups were conducted with 34 employees who did not receive training (Group A). Twenty focus groups were conducted with 125 employees after they had participated in a formal ServSafe training program (Group B). The following barriers were identified in at least one focus group in both Group A and Group B for all three practices: time constraints, inconvenience, inadequate training, and inadequate resources. In Group A, additional barriers identified most often were a lack of space and other tasks competing with cleaning work surfaces; inconvenient location of sinks and dry skin from handwashing; and lack of working thermometers and thermometers in inconvenient locations. Additional barriers identified most often by Group B were no incentive to do it and the manager not monitoring if employees cleaned work surfaces; inconvenient location of sinks and dry skin from handwashing; and lack of working thermometers and manager not monitoring the use of thermometers. Results will be used to develop and implement interventions to overcome perceived barriers that training appears not to address. Knowledge of perceived barriers among employees can assist dietetic professionals in facilitating employees in overcoming these barriers and ultimately improve compliance with food safety practices

Effects of observing employees for food safety compliance rates.

Research investigating foodservice employees’ compliance with food safety guidelines often utilizes observational methodology where an observer is present and recording employees’ behaviors as they work. Research must determine if the observer’s presence influences employees who are trained in food safety and those who are not. A group who had received a four‐hour ServSafe® food safety training course and a control group were included in the study (N=252). Both groups’ compliance rates were higher during the first hour of the observation compared to the last two hours of the observation. Implications for foodservice managers, researchers, and health inspectors are discussed

Intervention improves restaurant employees' food safety compliance rates

Abstract: Purpose – This paper aims to evaluate the relative effectiveness of four-hour ServSafe® food safety training, a theory-based intervention targeting food service employees' perceived barriers to implementing food safety practices, and a combination of the two treatments. Dependent measures include behavioral compliance with and perceptions of control over performing hand washing, use of thermometers, and handling of work surfaces. Design/methodology/approach – Four groups are compared: employees receiving only ServSafe® training, intervention alone, training and intervention, and no treatment. Employees complete a questionnaire assessing perceived barriers to practicing the targeted behaviors. Then, employees are observed in the production area for behavioral compliance. Findings – Training or intervention alone is better than no treatment, but the training/intervention combination is most effective at improving employees' compliance with and perceptions of control over performing the behaviors. Research limitations/implications – Research is limited to restaurant employees in three states within the USA, in only 31 of the 1,298 restaurants originally contacted. Future research should identify barriers of other types of food service employees and evaluate the effectiveness of these and other intervention strategies. Practical implications – ServSafe® training can be enhanced with a simple intervention targeting food service employees' perceived barriers to food safety. Providing knowledge and addressing barriers are both important steps to improving food safety in restaurants. Originality/value – No previous research has used the theory of planned behavior to develop an intervention targeting food service employees' perceived barriers to implementing food safety practices. Research also has not attempted to improve the effectiveness of ServSafe® food safety training by adding an intervention

Food safety training and foodservice employees' knowledge and behavior.

Statistics show that 59% of foodborne illnesses are traced to restaurant operations. Food safety training has been identified as a way to assure public health, yet evidence supporting the effectiveness of training has been inconclusive. A systematic random sample of 31 restaurants in three midwestern states was selected to assess the effect of training on food safety knowledge and behavior. A total of 402 employees (242 pretraining and 160 post-training) participated in this study. Pre and post-training assessments were conducted on knowledge and behavior related to three key food safety practices: cross contamination, poor personal hygiene, and time/temperature abuse. Overall knowledge (P ≥ .05) and compliance with standards of behavior (P ≥ .001) improved significantly between pre- and post-training. When each practice was examined independently, only handwashing knowledge (P ≥ .001) and behavior (P ≥ .001) significantly improved. Results indicated that training can improve knowledge and behaviors, but knowledge alone does not always improve behaviors

Food safety training requirements and food handlers' knowledge and behaviors

Very little research has evaluated how different types of food safety training requirements in foodservice establishments affect food handlers' performance. Foodservice employees (n = 242) from randomly selected restaurants from three Midwestern states within a 300-mile radius of the research institution completed a survey to assess their food safety knowledge and important behavioral antecedents (e.g., attitudes, intentions) related to food safety. Employees’ compliance with three important food safety behaviors (handwashing, use of thermometers, and proper handling of food and work surfaces)was observed. This study evaluated the effectiveness of two alternative food safety training requirements by comparing knowledge, behavioral antecedents, and behavioral compliance rates between two groups of food handlers: a group from restaurants in which food safety training is mandatory for all food handlers and a group from restaurants in which only shift managers must be knowledgeable about food safety. Mandating training for all food handlers was associated with improved compliance with some food safety behaviors; however, requiring that shift managers be knowledgeable about food safety appears to contribute similarly to employees' knowledge, behavioral antecedents, and compliance with regard to the three important food safety behaviors observed

Identifying specific beliefs to target to improve restaurant employees’ intentions for performing three important food safety behaviors

Current national food safety training programs appear ineffective at improving food safety practices in foodservice operations, given the substantial number of Americans affected by foodborne illnesses after eating in restaurants each year. The Theory of Planned Behavior (TpB) was used to identify important beliefs that may be targeted to improve foodservice employees' intentions for three food safety behaviors that have the most substantial affect on public health: hand washing, using thermometers, and proper handling of food contact surfaces. In a cross-sectional design, foodservice employees (n=190) across three midwestern states completed a survey assessing TpB components and knowledge for the three food safety behaviors. Multiple regression analyses were performed on the TpB components for each behavior. Independent-samples t tests identified TpB beliefs that discriminated between participants who absolutely intend to perform the behaviors and those with lower intention. Employees' attitudes were the one consistent predictor of intentions for performing all three behaviors. However, a unique combination of important predictors existed for each separate behavior. Interventions for improving employees' behavioral intentions for food safety should focus on TpB components that predict intentions for each behavior and should bring all employees' beliefs in line with those of the employees who already intend to perform the food safety behaviors. Registered dietitians; dietetic technicians, registered; and foodservice managers can use these results to enhance training sessions and motivational programs to improve employees' food safety behaviors. Results also assist these professionals in recognizing their responsibility for enforcing and providing adequate resources for proper food safety behaviors

Appreciation of food safety practices based on level of experience

This study sought to determine if no experience, basic experience, or well-informed experience (defined as basic experience and formal food safety training) in a foodservice operation would influence attitudes, subjective norms, and perceived behavioral control toward three important behaviors that can help prevent foodborne illness (handwashing, using thermometers, and sanitizing work surfaces). Results suggest that formal training increases respondents’ appreciation of the importance of these food safety practices. Those with formal food safety training identified more attitude, subjective norm, and perceived behavioral control constructs than participants with basic experience or no experience in foodservice. Factors that help and impede employees in following proper food safety practices were identified. Foodservice operators and sanitarians can utilize these results to employ strategies to address the barriers preventing employees from applying food safety practices and to increase compliance with food safety regulations during individual inspections within operations, respectively