Food Safety Knowledge and Behavior of Expanded Food and Nutrition Education Program Participants in Arizona

Transcription

1 1725 Journal of Food Protection, Vol. 63, No. 12, 2000, Pages Copyright, International Association for Food Protection Food Safety Knowledge and Behavior of Expanded Food and Nutrition Education Program Participants in Arizona RALPH R. MEER* AND SCOTTIE L. MISNER 309 Shantz Building, Department of Nutritional Sciences, The University of Arizona, Tucson, Arizona , USA MS 00-36: Received 7 February 2000/Accepted 17 July 2000 ABSTRACT Consumer education is one of the focus points to reduce foodborne illness within the food safety continuum from farm to table. A survey was conducted to determine the food safety knowledge and practices of the U.S. Department of Agriculture s Expanded Food and Nutrition Education Program participants in Maricopa and Pima counties of Arizona. Two hundred sixty-eight surveys were completed between 1 January and 31 December Survey participants consisted of 222 (85%) females and 39 (15%) males with an average age and education level of 31.5 and 11.7 years, respectively. The racial characteristics of this group included 53% whites, 32% Hispanics, 22% African-Americans, and 7% other. A majority of the survey participants (67%) were either unsure or felt it was appropriate to let food cool to room temperature prior to refrigeration. In addition 56% were in disagreement with or unsure about the need to cool foods in shallow containers. Fifty-two percent of respondents reported having no previous formal food safety education; for those who had, work was the most common source. Television news was the primary source of current food safety information for 50% of respondents. The most commonly consumed high-risk (i.e., raw or undercooked animal food or food purchased from unlicensed vendor) food was unpasteurized dairy products. Women scored significantly better than men on food safety knowledge and practice test parameters. Participants over age 50 had significantly higher food safety practice scores than the youngest age group. The food safety knowledge score of whites was significantly higher than that of Hispanics. It was determined for all participants that the food safety knowledge score had a small, positive effect on food safety practice score. The Expanded Food and Nutrition Education Program (EFNEP) is administered by the United States Department of Agriculture. Individuals participate in EFNEP on a voluntary basis. Participants are typically referred to EFNEP by social services agencies in the community. EFNEP does not provide food but offers food and nutrition education to participants from youth (early grade school) to adulthood. Individuals who participate in EFNEP are stated low income, although they are not required to provide documentation of actual income. In Arizona there are approximately 6,000 participants in EFNEP, half in adult programs and half in youth programs. In the past, characteristics common to EFNEP participants include being of low income, members of racial minorities, and having 12 years or less of education. It was anticipated that the food safety knowledge, behavior, and educational needs of the EFNEP population would correlate to those individuals of similar economic status, ethnicity, and educational level not participating in this program. The goal of this project was to assess the food safety knowledge and behavior of EFNEP participants in Maricopa and Pima counties. It was expected that this information would (i) assist in assessing the impact of current food safety messages on this group and (ii) identify their food safety education needs. Newly released statistics from the Centers for Disease Control estimate that foodborne diseases are responsible for * Author for correspondence. Tel: ; Fax: ; rmeer@u.arizona.edu. approximately 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths per year (7). Estimates of the cost of foodborne illness in the United States range from $4 to $23 billion per year (5, 8, 9). Food safety is an area of increasing concern and attention. The new focus on food safety encompasses the food safety continuum frequently described as gate to plate, farm to fork, etc. Multiple government agencies, as well as various agriculture and food-related industries and associations, are developing and implementing food safety programs, regulations, and training specific to their area of the food system. Consumer food safety education has been identified as a top priority in the 1997 National Food Safety Initiative. Over the past 5 to 10 years a number of consumer-based food safety surveys or audits have been administered to a variety of populations (1, 2, 10 12). Although these studies have shown that there is an increased awareness of foodborne illness in general, a significant number of individuals continue to (i) lack the specific knowledge necessary to control food safety hazards and (ii) report the consumption of high-risk foods, defined as raw or undercooked animal foods or foods sold by unlicensed vendors. MATERIALS AND METHODS Subjects. A food safety survey was administered to 268 participants of the United States Department of Agriculture s EFNEP in Maricopa and Pima counties of Arizona. EFNEP participants completed the surveys, upon their entry into the program, between 1 January and 31 December 1998 under the supervision of county

2 1726 MEER AND MISNER J. Food Prot., Vol. 63, No. 12 TABLE 1. Characteristics of survey participants Gender Female Male Race White Hispanic African-American Other Characteristic Pima Maricopa Total (85%) 39 (15%) 142 (53%) 86 (32%) 22 (8%) 18 (7%) Age Average (range) 29.4 (13 78) 33.5 (15 68) 31.5 (13 78) Education level Average years completed (range) 11.7 (6 18) 11.7 (5 20) 11.7 (5 20) EFNEP agents. The completed surveys were collected by the EF- NEP agents and returned to the investigators in the Department of Nutritional Sciences at the University of Arizona for analysis. Questionnaire. The survey was adapted from (i) the Centers for Disease Control and Prevention s Behavioral Risk Factor Surveillance System and (ii) the Food Marketing Institute s Consumer Attitudes and the Supermarket Survey (4, 14). The three-page survey consisted of 34 questions. Nine questions covered background information, 11 concerned food safety knowledge, 10 addressed food safety practices, and 4 related to information about foodborne disease outbreaks. The food safety knowledge and food safety practice questions were further subdivided into two categories: (i) the consumption of high-risk foods and (ii) food handling and preparation. Analysis. Scores for each test category (i.e., food safety knowledge, food safety practices, consumption of high-risk foods, TABLE 2. Responses to selected food safety statements Statement Disagree (%) Not sure (%) Agree (%) Food that can make you sick always smells or tastes bad Leftovers should be allowed to cool to room temperature before being refrigerated Leftovers should be stored in the container they are cooked in Leftovers should be stored in shallow containers 2 to 4 in. deep to allow for proper cooling Freezing kills all bacteria that may cause foodborne illness Bacteria that cause foodborne illness grow well at room temperature Foodborne illness can result from the contamination of ready-to-eat foods with juices from raw animal foods Ground beef needs to be cooked to a higher temperature than steaks or roasts to assure adequate safety against disease-causing bacteria food handling and preparation) were calculated by assigning correct responses a value of one, incorrect responses a value of minus one, and other responses (e.g., don t know, unsure, refuse to answer) as zero. Statistical analyses were performed utilizing SPSS for Windows 9.0 (SPSS Inc., Chicago, Ill.). Independent-sample t tests (confidence interval 95%) were used to compare selected test parameters (e.g., education level, food safety knowledge score, food safety practice score, consumption of high-risk foods score, food safety preparation and handling score) with gender (male vs. female) and county of residence (Pima vs. Maricopa). Multiple analysis of variance procedures with Tukey s test for multiple comparisons (significance level 0.05) were used to compare factors with more than two independent variables (e.g., education level, age group, and race) against the same test parameters mentioned above. A bivariate correlation using Pearson s correlation coefficient was used to determine if food safety knowledge scores correlated with food safety practice scores. RESULTS Characteristics of our survey participants are listed in Table 1. The majority of participants were female (85%), predominately white (53%) or Hispanic (32%), had an average age of 31.5 years (range 13 to 78), and an average education level of 11.7 (range 5 to 20) years of school. Table 2 contains selected food safety statements and corresponding participant responses. Almost one-third believed that food that can make you sick can be identified by taste or smell. Fifty-four percent believed it was appropriate to let food cool to room temperature before being refrigerated. Although most participants knew it was best to transfer food to a different container for storage, slightly more than half did not know or were unsure of the proper depth to store food to allow for an adequate rate of cooling. The majority of participants (75%) knew that bacteria responsible for causing foodborne illness grow at room temperature. Seventy-nine percent also know to avoid cross contamination of ready-to-eat foods with juices from raw animal products. Approximately two-thirds of participants were aware that ground beef required a higher cooking temperature than did roasts or steaks for pasteurization. A summary of previous food safety education, sources of current food safety information, and knowledge of foodborne disease outbreaks is given in Table 3. Approximately

3 J. Food Prot., Vol. 63, No. 12 CONSUMER FOOD SAFETY 1727 TABLE 3. Summary of previous food safety education, source of current food safety information, and knowledge of foodborne disease outbreaks Characteristic Previous food safety education None Work School Main source of current food safety information TV news Newspaper Family Foods associated with E. coli foodborne disease outbreaks (last 5 years) Beef red meat Chicken poultry Foods associated with Salmonella foodborne disease outbreaks (last 5 years) Chicken poultry Eggs Foods associated with Campylobacter foodborne disease outbreaks (last 5 years) Beef meat Chicken poultry Fish seafood List other foodborne diseasecausing organisms and foods associated with outbreaks Botulism canned food Trichinosis pork Top three answers n 197 respondents a 102 (52%) 28 (14%) 24 (12%) n 233 respondents a 116 (50%) 25 (11%) 17 (7%) a Summary includes top three answers only, therefore percentages do not total 100%. half of the survey participants who provided an answer indicated that they had no previous formal food safety instruction or training. Of the ones who had, most received it at work or school. There was no significant difference in food safety knowledge or practices scores between those who received their food safety education from school, work, or other sources (data not included). In addition, although participants with previous food safety education had significantly higher food safety knowledge scores (P 0.01) compared to those who indicated they did not, the difference in food safety practices between these two groups was not significant. The average age of individuals having received food safety education in a health class was 15.8 years, those who reported getting food safety education in high school or home economics had an average of 26.8 years, and those having received food safety education in college had an average age of 35.2 years. The main source of current food safety information was television news. Participants were somewhat familiar with the foods associated with the majority of foodborne outbreaks related to E. coli and Salmonella but were unfamiliar with those associated with Campylobacter foodborne illness or other foodborne pathogens. Table 4 contains information on the frequency of consumption of selected high-risk foods. The most commonly consumed high-risk food was raw milk or a raw milk product, while the least likely to be consumed was raw or undercooked poultry. Responses to additional food safety statements or questions are listed in Table 5. Most participants were unaware of the temperature of their refrigerator, and a small majority knew that a large number of foodborne illnesses involve foods prepared at home. Sixty percent were aware that it was best to refrigerate perishable food promptly and to use appropriate methods (refrigerator, microwave, cold water) to defrost foods. Eighty percent of participants selected all five activities listed that should be followed by hand washing, while only a few (6%) were able to identify the four food safety reminders on food handling labels provided with raw meats and poultry products. A comparison of scores for selected test parameters by county of residence, using a t test for independent variables, revealed a difference approaching significance in food safety practice scores only (Table 6). A gender comparison of scores for selected test parameters (Table 7) revealed that TABLE 4. Consumption frequency of selected high-risk foods a Food product Regularly, Rarely, Never, Refused to answer, Raw or undercooked meat Raw or undercooked poultry Raw or undercooked eggs or egg dishes Raw or undercooked fish Raw or undercooked seafood Raw milk or raw milk products Purchased food from unlicensed vendor 37 (14) 6 (2) 35 (13) 28 (10) 20 (7) 109 (41) 46 (17) 9 (3) 5 (2) 22 (8) 21 (8) 7 (3) 41 (15) 178 (66) 222 (83) 189 (70) 189 (70) 200 (75) 125 (47) 155 (58) 23 (9) 25 (9) 20 (7) 12 (4) a n 268, remainder of responses were not sure.

4 1728 MEER AND MISNER J. Food Prot., Vol. 63, No. 12 TABLE 5. Responses to selected food safety statements and questions Statement/question Possible answers Answers selected, The temperature of my refrigerator is set at Which of the following area in the food system contributes to the greatest number of foodborne illnesses? Perishable foods in my home are left at room temperature for greater than 2 h Raw animal food products are usually thawed in my home by Hand washing with soap and water should occur (circle all that apply) Food-handling labels on raw meat and poultry provide reminders on which food safety practices? (circle all that apply) a. 50 F b. 45 F c. 41 F d. Other e. a. Home b. Food service c. Food processor d. Source e. (Selected 1) a. Frequently b. Occasionally c. Never d. Not sure a. Counter b. Refrigerator c. Microwave d. Other e. a. Before preparing or handling food. b. After handling raw animal foods. c. After sneezing, coughing, or touching your face. d. After using rest room/changing diapers. e. After touching pets. a. Proper cooking b. Avoidance of cross contamination c. Appropriate sanitizing agents d. Proper thawing methods e. Proper storage temperatures f. Not sure a. 12 (4) b. 19 (7) c. 43 (16) d. 10 (4) e. 184 (69) a. 91 (34) b. 76 (28) c. 40 (15) d. 38 (14) e. 23 (9) a. 12 (4) b. 59 (22) c. 160 (60) d. 37 (14) a. 57 (21) b. 110 (41) c. 31 (12) d. Correct 17 (6) d. Incorrect 36 (14) e. 17 (6) 41 (16) selected 1 5 (2) selected 3 6 (2) selected (80) selected 5 38 (14) selected 1 17 (6) selected 2 to 4 16 (6) selected correct 4 41 (15) selected all 156 (58) selected f females had a significantly (P 0.05) higher education level and scores for food safety knowledge, food safety practices, consumption of high-risk foods, and food preparation or handling. Although the number of female participants (n 229) was larger than the number of male participants (n 39), it was felt that the latter number was sufficient to provide a normal distribution and the hypothesis of equal variances between the two groups (male and female) was not rejected using Levene s test (data not shown). Individuals with an education level beyond 12 TABLE 6. Comparison of scores for selected test parameters by county of residence Pima (n 148) Maricopa (n 120) Education highest grade complete Food safety knowledge Food safety practices a a Consumption of high-risk foods Food safety preparation and handling a Significant difference in means (P 0.05). TABLE 7. Comparison of scores for selected test parameters by gender Male (n 39) Female (n 229) level, P Education highest grade complete Food safety knowledge Food safety practices Consumption of highrisk foods a Food safety preparation and handling a Higher score indicates fewer high-risk foods were consumed.

5 J. Food Prot., Vol. 63, No. 12 CONSUMER FOOD SAFETY 1729 TABLE 8. Comparison of scores for selected test parameters by education level a Group 1 a (n 105) Group 2 a (n 95) Group 3 a (n 68) level, P Food safety knowledge Food safety practices Consumption of high-risk foods Food safety preparation and handling A A B B A,B A,B Not significant Not significant a Education level by highest grade completed: group 1 ( 12); group 2 (12 or GED); group 3 ( 12). Values with the same letter are significantly different from each other. years had significantly higher (P 0.001) food safety knowledge and food preparation and handling scores (Table 8) than those with a 12th grade education or less. Older participants ( 50 years of age) had significantly greater (P 0.01) food safety practice scores than participants from the youngest age group (i.e., 25) (Table 9). In addition, the youngest age group s education level was significantly less (P 0.001) than that of the other two age groups. With respect to race, the only test parameter that demonstrated a significant difference (P 0.001), was the food safety knowledge score obtained by whites compared to Hispanics (Table 10). A Pearson s correlation coefficient of (P 0.05 level) indicated a weak but significant, positive relationship between the food safety knowledge score and the food safety practice score (Fig. 1). DISCUSSION A number of individuals (39%) were unaware or unsure that food capable of causing illness is not always recognizable by sight or smell. This compares with 16% observed in a previous study by Williamson et al. (11). The most frequently consumed high-risk foods were raw dairy products, followed by raw or undercooked beef. This suggests a preference for these two types of high-risk foods. Although participants were familiar with foods associated with Escherichia coli and Salmonella, few were knowledgable about foods associated with Campylobacter or other agents of foodborne illness. Research done by Woodburn and Raab (12) indicated that the popular media was responsible for increased awareness of the foods associated with E. coli- and Salmonella- related foodborne illness. Nevertheless, 25% of persons in their survey reported that they still consumed rare or undercooked hamburgers. A prominent error in food handling practices was temperature abuse with respect to the proper cooling and thawing of foods. Temperature abuse was a common error seen in the assessments done by Williamson et al. (11) and Worsfold and Griffith (13) as well. Similar to the age-related differences in answers to food safety knowledge and practice questions seen by Williamson et al. (11) (i.e., individuals over 35 had higher scores), our survey showed that age group 3 ( 50 years) had significantly higher food safety practice scores than participants from age group 1 ( 25 years). However, there was no difference in the other food safety parameter scores between age groups. In contrast, Woodburn and Raab (12) reported that between 50 and 60% of younger respondents could identify a risk group compared to 0% of those over 65 years of age. The difference in average age of individuals having received previous food safety education in health (15.8), high school or home economics (26.8), and college (35.2) most likely reflects individuals who did not or have not yet gone on to additional education or are otherwise reporting their most recent formal food safety education experience. Food safety education from school, work, or other source seemed equivalent because the food safety knowledge and practice scores between the three groups were not significantly different. Although individuals with previous food safety education had more food safety knowledge compared to those without previous food safety education, this knowledge did not seem to be put into practice. Although food safety knowledge scores as well as preparation and handling scores were significantly higher among participants with the highest education level (i.e., 12th grade), there was no difference seen in food safety practice scores or the likelihood of consuming high-risk TABLE 9. Comparison of scores for selected test parameters by age group a Group 1 a (n 100) Group 2 a (n 127) Group 3 a (n 41) level, P Food safety knowledge Food safety practices Consumption of high-risk foods Food safety preparation and handling Education level A ( ) A,B ( ) A A ( ) B a Age group; group 1 ( 25); group 2 (26 to 49); group 3 ( 50). Values with the same letter are significantly different from each other.

6 1730 MEER AND MISNER J. Food Prot., Vol. 63, No. 12 TABLE 10. Comparison of scores for selected test parameters by race a Group 1 (n 140) Group 2 (n 91) Group 3 (n 21) Group 4 (n 16) level, P Food safety knowledge Food safety practices Consumption of high-risk foods Food safety preparation and handling Education level A A a Race grouping: group 1 (white); group 2 (Hispanic); group 3 (African-American); group 4 (other; includes Asian/pacific and native american). Values with the same letter are significantly different from each other. foods among the participants in the three education levels. Other studies have also reported that food safety knowledge was directly proportional to education level (1, 11). Woodburn and Raab (12) found that although those with a higher education level were less concerned with the freshness of raw meat and poultry items compared to those with a lower education level, the incidence of foodborne illness was not associated with educational level. Fein et al. (3) reported that there was a greater incidence of foodborne illness among those with at least some college education. Female participants in our study demonstrated a significantly high score in each test parameter compared to men. This was consistent with some of the literature as Altekruse et al. (1, 2) found that men were more likely to report engaging in risky practices than women and Williamson et al. (11) observed that women had a higher mean food safety knowledge score than men. Although, Woodburn and Raab (12) reported that gender differences were not significant in their study. The knowledge and practice level concerning food safety among consumers in this population indicates a need for improvement. However, as seen in this and other studies, food safety knowledge, training, and education level do not always correspond with the implementation of appropriate behaviors to prevent or reduce foodborne illness. For example, McIntosh et al. (6) found that awareness of specific pathogens and procedures to ensure levels of food safety did not impact consumer willingness to change behavior. Consumers need specific messages about the control measures to prevent or reduce the potential for illness to occur. From a priority standpoint, these messages should focus on those who are at high risk for foodborne illness, followed by those who have demonstrated the greatest need (e.g., young adults and/or less experienced food handlers). Research providing information on (i) the parameters influencing food selection including barriers for adopting behaviors and practices associated with reducing risks for foodborne illness and (ii) the most appropriate and effective methods for delivering food safety messages will support the delivery of successful consumer education efforts. ACKNOWLEDGMENTS The University of Arizona s Small Grant Proposal Office, Office of the Vice President of Research, provided funding for this project. Assistance provided by the EFNEP agents in Maricopa and Pima county as well as Pat Jones, Center for Computing and Information Technology User Services Research Support, University of Arizona was invaluable. REFERENCES FIGURE 1. Prediction of food safety practice scores based on food safety knowledge scores of survey participants. 1. Altekruse, S. F., D. A. Street, S. B. Fein, and A. S. Levy Consumer knowledge of foodborne microbial hazards and food-handling practices. J. Food Prot. 59: Altekruse, S. F., S. Yang, B. B. Timbo, and F. J. Angulo A multi-state survey of consumer food-handling and food-consumption practices. Am. J. Prev. Med. 16: Fein, S. B., C.-T. J. Lin and A. S. Levy Foodborne illness: perceptions, experience, and preventive behaviors in the United States. J. Food Prot. 58: Food Marketing Institute Trends in the United States: consumer attitudes and the supermarket, Food Marketing Institute. Washington, D.C. 5. Gathright, W. E., D. L. Archer, and J. E. Kvenberg Estimates of the incidence and costs of intestinal diseases in the United States. Public Health Rep. 103: McIntosh, W. A., L. B. Christensen and G. R. Acuff Perceptions of risks of eating undercooked meat and willingness to change cooking practices. Appetitie 22:83 96.

7 J. Food Prot., Vol. 63, No. 12 CONSUMER FOOD SAFETY Mead, P. S., L. Slutsker, V. Dietz, L. F. McCaig, J. S. Bresee, C. Shapiro, P. M. Griffin, and R. V. Tauxe Food-related illness and death in the United States. Emerg. Infect. Dis. 5: Roberts, T., and D. Smallwood Data needs to address economic issues in food safety. Am. J. Agric. Econ. 73: Todd, E. C. D Preliminary estimates of costs of foodborne disease in the United States. J. Food Prot. 52: Unklesbay, N., J. Sneed, and R. Toma College students attitudes, practices, and knowledge of food safety. J. Food Prot. 61: Williamson, D. M., R. B. Gravani, and H. T. Lawless Correlating food safety knowledge with home food-preparation practices. Food Technol. 46:94, 96, 98, Woodburn, M. J., and C. A. Raab Household food preparers food-safety knowledge and practices following widely publicized outbreaks of foodborne illness. J. Food Prot. 60: Worsfold, D., and C. J. Griffith Assessment of the standard of consumer food safety behavior. J. Food Prot. 60: Yang, S., M. G. Leff, D. McTague, K. A. Horvath, J. Jackson- Thompson, T. Murayi, G. K. Boeselager, T. A. Melnik, M. C. Gildemaster, D. L. Ridings, S. F. Altekruse, and F. J. Angulo Multistate surveillance for food-handling, preparation, and consumption behaviors associated with foodborne diseases: 1995 and 1996 BRFSS food safety questions. Morbid. Mortal. Weekly Rep. 47(SS- 4):33 54.