Qualitative studies of the food safety knowledge and perceptions of transplant patients.

Organ and stem cell transplant patients are at risk for foodborne illness due to disease and medically induced immunosuppression. The food safety knowledge and informational needs of these groups have not been documented in the literature. The objectives of this study were to assess transplant patients' food safety knowledge and perceptions, to probe the likelihood of practicing safe food handling behavior, and to test an educational strategy for future food safety interventions aimed at transplant patients. Subjects were organ or stem cell transplant patients, or their family care providers. Research was conducted in inpatient or outpatient facilities at a large, Midwestern United States comprehensive cancer and transplant center. Differences in survey data between the organ and stem cell transplant groups were determined by Student's t tests. Ethnographic methods were used to analyze qualitative focus groups and interview data for themes. Organ transplant patients had less motivation to follow food safety recommendations than did stem cell transplant patients, and they were more likely to consume risky foods. Stem cell transplant patients overall had a better understanding of their susceptibility to foodborne illness and had better prepared themselves with the knowledge and behavior changes needed to protect their health. Educational materials aimed at communicating food safety information for transplant patients were evaluated by patients and judged acceptable. This study found that organ transplant and stem cell transplant patients are distinct patient populations, with differing perceptions regarding the seriousness of foodborne illness and willingness to adopt preventative food handling practices. Population differences should be accounted for in food safety educational strategies.

Discovery and development of educational strategies to encourage safe food handling behaviors in cancer patients.

Foodborne infections pose a threat to cancer patients who are immunocompromised because of disease or medical therapy. Comprehensive food safety education can raise cancer patients' awareness of risk for foodborne infections and encourage risk-reducing behavior. The objectives of this study were to assess food safety informational needs of cancer patients and to determine factors that may influence prospective educational interventions that foster risk-reducing behaviors. Focus groups with cancer patients were formed, and interviews with health professionals working with cancer patients were conducted. Findings were used to develop three educational resource prototypes for cancer patients. Information from two additional focus groups and interviews with cancer patients was used to evaluate the prototypes before revision and finalization. There was a general awareness among focus group participants that chemotherapy increased their susceptibility to foodborne illness and infections. Participants had a basic knowledge of safe food handling practices but did not necessarily link their awareness of increased susceptibility for infection with their routine food handling practices. When informed of specific high-risk foods, there was skepticism about compliance due to disbelief of the risk, personal preferences for the high-risk food, and lack of information about how to use the recommendation. Most of the health care providers agreed that food safety information should be provided by dietitians, physicians, and nurses, but physicians stated they had little time to do so. Cancer patients expressed positive attitudes toward the educational resource prototypes and willingness to follow the food safety recommendations provided.

Development and validation of stages-of-change questions to assess consumers' readiness to use a food thermometer when cooking small cuts of meat.

Consumers' readiness to use a food thermometer when cooking small cuts of meat was assessed using Prochaska's Transtheoretical Model of Behavior Change. Face, content, and concurrent validity were assessed by peer review, cognitive interviews, and mail surveys. The self-administered mail survey was sent to two groups of Washington and Idaho residents: 1,000 randomly selected consumers (41% return rate), and 231 employees and volunteers of Cooperative Extension involved in food and nutrition education (60% return rate). Two-stage classification questions were compared with a behavior question about thermometer use, and validated using Cronbach's if-item-deleted option for alpha. Concurrent validity was assessed using cross-tabulation chi2 test. The detailed classification question more accurately classified respondents in both Consumer and Extension groups. Cronbach's alpha of the detailed question with the behavior question showed a consistency level of alpha=.73 compared to alpha=.35 for the simple question format. As expected, Consumer and Extension groups differed significantly in their stages of change (P<0.0001), verifying concurrent validity. We recommend use of the detailed classification question when staging persons related to food thermometer use. The process used for development and testing can be used to refine instruments for use in other types of interventions.

Application of a five-step message development model for food safety education materials targeting people with HIV/AIDS.

Individuals with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome have an increased risk of contracting foodborne illnesses and need to take special precautions regarding food safety. We implemented a five-step model to assess the needs of people with HIV, develop education materials targeted to their needs, and evaluate acceptance of the materials. Needs assessment focus groups (n=8) with HIV-infected people (n=65) and interviews with health care providers (n=18) were conducted to determine motivators and barriers to adopting food safety recommendations. Education materials were developed using needs assessment data, literature on foodborne illnesses, and the Health Belief Model. Acceptability of materials was evaluated by focus groups (n=4) with HIV-infected people (n=32) and a survey of health care providers (n=25). Needs assessment focus group participants expressed resistance to and confusion about many recommendations. Prototype materials were designed to address barriers and motivators. HIV-infected people who reviewed the prototype materials in evaluation focus groups expressed positive attitudes about the materials, and most indicated willingness to follow recommendations. Health care providers were interested in distributing the education materials to their clients. Carefully listening to HIV-infected people and their health care providers, as well as detailed investigation of the literature on foodborne illnesses, contributed to acceptance of the education materials.

Educational intervention enhances consumers' readiness to adopt food thermometer use when cooking small cuts of meat: an application of the transtheoretical model.

An intervention to promote use of food thermometers when cooking small cuts of meat was conducted using the Transtheoretical Model. Objectives were to (i) increase use of food thermometers by home food preparers, (ii) improve consumers' attitudes regarding use of a food thermometer, and (iii) examine relationships between stages of change and decisional balance, self-efficacy, and processes of change. A randomly selected group of residents of Washington and Idaho (n = 2,500) were invited to participate in the research; 295 persons completed all phases of the multistep intervention. Following the intervention program, there was a significant increase in food thermometer use when cooking small cuts of meat (P < 0.01); those persons classified in action and maintenance stages increased from 9 to 34%. Ownership of thermometers also significantly increased (P < 0.05). The three constructs related to the Transtheoretical Model that were used in the study (decisional balance, self-efficacy, and processes of change) were very useful for examining differences among people at different stages of change because the responses for each set of questions differed positively and significantly (P < 0.01) as stages of change classifications advanced from precontemplation (no interest in thermometer use) to action and maintenance (individuals who use food thermometers). Additional educational campaigns designed to increase use of food thermometers are needed. Because most consumers are currently in the precontemplation stage, food thermometer campaigns will be most effective when they are focused on raising awareness of the food safety risks and the benefits of using food thermometers when cooking small cuts of meat.

Observation versus self-report: validation of a consumer food behavior questionnaire.

A reliable and validated set of food safety behavior questions that could be used with confidence when evaluating food safety education programs was identified in this study. A list of 29 food-handling and consumption behaviors rank-ordered within five pathogen control factors by nationally recognized food safety experts was the basis for the development of the behavior questions. Questions were evaluated for reliability and several forms of validity. During a kitchen activity session, 70 graduates of a nutrition education program completed four food preparation tasks while being observed and videotaped. The individuals also participated in an in-depth interview to validate behaviors that could not be observed during the food preparation activity, e.g., refraining from preparing food for others when experiencing diarrhea. Criterion validity was established by comparing questionnaire responses to observed behavior and interview responses. Twenty-eight questions met the validity criterion (> or = 70% agreement between observed and interviewed responses and self-reported responses), with three or more questions from each of five pathogen control factor areas. Observation assessments revealed that hand washing was more likely to be performed prior to beginning food preparation than between working with raw meats and fresh produce. Errors in methods of washing hands, utensils, and preparation surfaces between food preparation tasks were common. Most participants did not use thermometers to evaluate doneness but still cooked to safe internal temperatures. The results provide a tool that educators can use to evaluate food safety programs and will help guide the development of more effective food safety education programs targeting needed improvements in behavioral skills.

Design and development of food safety knowledge and attitude scales for consumer food safety education.

OBJECTIVE: The objective of this study was to design and develop food safety knowledge and attitude scales based on food-handling guidelines developed by a national panel of food safety experts. DESIGN: Knowledge (n=43) and attitude (n=49) questions were developed and pilot-tested with a variety of consumer groups. Final questions were selected based on item analysis and on validity and reliability statistical tests. SUBJECTS/SETTING: Knowledge questions were tested in Washington State with participants in low-income nutrition education programs (pretest/posttest n=58, test/retest n=19) and college students (pretest/posttest n=34). Attitude questions were tested in Ohio with nutrition education program participants (n=30) and college students (non-nutrition majors n=138, nutrition majors n=57). STATISTICAL ANALYSES PERFORMED: Item analysis, paired sample t tests, Pearson's correlation coefficients, and Cronbach's alpha were used. RESULTS: Reliability and validity tests of individual items and the question sets were used to reduce the scales to 18 knowledge questions and 10 attitude questions. The knowledge and attitude scales covered topics ranked as important by a national panel of experts and met most validity and reliability standards. The 18-item knowledge questionnaire had instructional sensitivity (mean score increase of more than three points after instruction), internal reliability (Cronbach's alpha >.75), and produced similar results in test-retest without intervention (coefficient of stability=.81). Knowledge of correct procedures for hand washing and avoiding cross-contamination was widespread before instruction. Knowledge was limited regarding avoiding food preparation while ill, cooking hamburgers, high-risk foods, and whether cooked rice and potatoes could be stored at room temperature. The 10-item attitude scale had an appropriate range of responses (item difficulty) and produced similar results in test-retest ( P

Food safety issues for cancer and organ transplant patients.

This paper explores reasons why cancer and transplant patients are at greater risk for food-borne illnesses and which pathogens and food-handling behaviors are of particular concern. Cancer and bone marrow transplant patients experience neutropenia because of medical treatments, whereas patients with solid organ transplants become immunosuppressed from a pharmacological regimen to prevent rejection of the transplanted organ. Opportunistic infections, including food-borne illnesses, may occur during periods of immunosuppression. Food-handling behaviors and practices to control food-borne illnesses were presented to focus groups and during interviews with cancer and transplant patients and health care providers. Credibility of the food safety information, credibility of the person providing the advice, and sensitivity to the restrictions imposed on the patient's lifestyle by food safety guidance were key themes from the focus group and interview study. The information gathered will help health care providers aid the cancer or transplant patient with their knowledge and understanding of food safety and their greater risk for food-borne infections.

Consumer food-handling behaviors associated with prevention of 13 foodborne illnesses.

To be effective in reducing the incidence of foodborne illness, consumers and food safety educators need information about behaviors that will decrease exposure to foodborne pathogens. A four-round Delphi technique was used to survey nationally recognized experts in food microbiology, epidemiology, food safety education, and food safety policy with the aim of identifying and ranking food-handling and consumption behaviors associated with 13 major foodborne pathogens. The food safety experts ranked behaviors related to keeping foods at safe temperatures as of primary importance in preventing illness caused by Bacillus cereus and Clostridium perfringens and of secondary importance in preventing illness caused by Staphylococcus aureus. The use of a thermometer to cook foods adequately was ranked as of primary importance for the prevention of illness caused by Campylobacter jejuni, Salmonella species, Escherichia coli O157:H7, Toxoplasma gondii, and Yersinia enterocolitica, with the avoidance of cross-contamination being ranked as of secondary importance for most of these pathogens. Hand washing was the top-ranked behavior for the prevention of shigellosis. The avoidance of certain foods that are likely to be contaminated was the top-ranked behavior for the prevention of illnesses caused by Listeria monocytogenes, Noroviruses, and Vibrio species. The expert panel's ranking of behaviors for the reduction of the risk of illness caused by major foodborne pathogens can enable consumers to make informed choices about food consumption and handling behaviors and can guide food safety educators in prioritizing their educational efforts.

Evaluation of consumer-style cooking methods for reduction of Escherichia coli O157:H7 in ground beef.

The objective of this study was to evaluate the thermal inactivation of Escherichia coli O157:H7 in ground beef cooked to an internal temperature of 71.1 degrees C (160 degrees F) under conditions simulating consumer-style cooking methods. To compare a double-sided grill (DSG) with a single-sided grill (SSG), two different cooking methods were used for the SSG: for the one-turnover (OT-SSG) method, a patty was turned once when the internal temperature reached 40 degrees C, and for the multiturnover (MT-SSG) method, a patty was turned every 30 s. Patties (100 g, n = 9) inoculated with a five-strain mixture of E. coli O157: H7 at a concentration of 10(7) CFU/g were cooked until all three temperature readings (for two sides and the center) for a patty were 71.1 degrees C. The surviving E. coli O157:H7 cells were enumerated on sorbitol MacConkey (SMAC) agar and on phenol red agar base with 1% sorbitol (SPRAB). The order of the cooking methods with regard to the cooking time required for the patty to reach 71.1 degrees C was as follows: DSG (2.7 min) < MT-SSG (6.6 min) < OT-SSG (10.9 min). The more rapid, higher-temperature cooking method was more effective (P < 0.01) in destroying E. coli O157:H7 in ground beef. E. coli O157:H7 reduction levels were clearly differentiated among treatments as follows: OT-SSG (4.7 log10 CFU/g) < MT-SSG (5.6 log10 CFU/g) < DSG (6.9 log10 CFU/g). Significantly larger numbers of E. coil O157:H7 were observed on SPRAB than on SMAC agar. To confirm the safety of ground beef cooked to 71.1 degrees C, additional patties (100 g, n = 9) inoculated with lower concentrations of E. coli O157:H7 (10(3) to 10(4) CFU/g) were tested. The ground beef cooked by the OT-SSG method resulted in two (22%) of nine samples testing positive after enrichment, whereas no E. coli O157:H7 was found for samples cooked by the MT-SSG and DSG methods. Our findings suggest that consumers should be advised to either cook ground beef patties in a grill that cooks the top and the bottom of the patty at the same time or turn patties frequently (every 30 s) when cooking on a grill that cooks on only one side.