Results of the home food safety—It’s in your hands 2002 survey: Comparisons to the 1999 benchmark survey and healthy people 2010 food safety behaviors objective

Practice BEYOND THE HEADLINES

Results of the Home Food Safety—It’s in Your Hands 2002 Survey: Comparisons to the 1999 Benchmark Survey and Healthy People 2010 Food Safety Behaviors Objective MILDRED M. CODY, PhD, RD; MARY ANNE HOGUE, MS, RD, FADA

oodborne illness is both a widespread public health and economic problem (1-7) and a clinical problem (8-13). Estimates of foodborne illness from the Centers for Disease Control and Prevention suggest that, on average, Americans suffer from foodborne illness about once every five years (1). Even more conservative estimates imply that individuals in the United States are likely to experience foodborne illness at least once within their lifetime (14). Although individuals who have weakened immune systems are more susceptible to foodborne illness and typically exhibit more severe consequences from these illnesses (8,9, 11,12,15,16), all individuals exhibit susceptibility to major pathogens (16).

F

Consumer Food Handling and Foodborne Illness Epidemiologic evidence shows that consumer food-handling and sanitation practices play a major role in foodborne illness (2,4,15,17-19). Furthermore, although larger outbreaks are more typically reported and confirmed, much foodborne disease is likely to be sporadic, unconfirmed, and unreported (15,18). Also, although foodborne disease can be acutely fatal (3,4,8-11,16), have important secondary complications (3, 13,16,20), and increase short- and longterm mortalities for individuals with existing diseases (8,9,11,15,16), most cases resolve in a short time without documented aftereffects (1,16). Therefore,

M. M. Cody is an associate professor in the Department of Nutrition, Georgia State University, Atlanta, and is a member of the ADA/ConAgra Foods Home Food Safety . . . It’s in Your Hands Expert Panel. M. A. Hogue is Vice President Food Safety Services, The Steritech Group, Inc., Charlotte, NC, and is Chair, ADA/ConAgra Foods Home Food Safety . . . It’s in Your Hands Expert Panel. doi: 10.1053/jada.2003.50594

from an epidemiologic standpoint, incidence of foodborne disease is hard to measure and to predict (1-4). From a consumer standpoint, foodborne disease is a rare event for a single eating episode, even when recommended practices are not followed (14). Although food safety regulations are monitored in surveillance programs, consumer kitchens do not have the benefits of outside monitoring and depend upon consumers who are knowledgeable and whose behaviors are informed by recommended practices. Surveys of Consumer Food Handling Surveys are frequently used to collect data on consumer knowledge, attitudes, and self-reported behaviors (19,21-34). Although knowledge and self-reported behaviors do not always correspond to actual behaviors in free-living situations, they provide evidence of what consumers know. They also provide evidence of how consumers apply this information in their decision making, even if their actual behaviors fall short of their ideals (17,18, 28,31-33,35-37). Additionally, larger, welldesigned surveys give a clearer picture of public norms than smaller, observational studies give. Information obtained from consumers can be used to shape educational programs and to motivate consumers to make healthful changes in their food-handling and sanitation behaviors (2,17,19,21-29,31-33,35-37). Food Safety Messages for Consumers Home Food Safety . . . It’s in Your Hands (HFSYH), developed and implemented by the American Dietetic Association (ADA) and the ConAgra Foods Foundation (38), and FightBAC!, developed and implemented by the Partnership for Food Safety Education (PFSE) (39), are two national programs that are working to promote effective consumer food handling and sanitation. The four primary messages—Chill, Cook, Clean, and Sepa-

rate—were originally developed for the FightBAC! program and were adapted by HFSYH to deliver messages more specific to primary food preparers in households with young families. The HFSYH messages are the following: “Wash hands often,” “Keep raw meat and ready-to-eat foods separate,” “Cook to proper temperatures,” and “Refrigerate promptly below 40°F.” These primary messages are presented in both general and detailed formats over a wide range of educational programming throughout the United States. Public Health Food Safety Behavior Goals for Consumers Healthy People 2010 (HP 2010) (40), the United States public health blueprint for the decade from 2000 to 2010, includes a food safety goal: “Reduce foodborne illnesses.” One objective that supports this goal is to “Increase the proportion of consumers who follow key food safety practices.” These key practices are based on the four FightBAC! messages, expressed as “clean—wash hands and surfaces often,” “separate— don’t cross-contaminate,” “cook— cook to proper temperatures,” and “chill—refrigerate promptly.” The baseline data for this goal show that “72% of consumers followed key food safety practices in 1998, based on total population of adults who engaged in the practice.” The HP 2010 goal is to increase this percentage to 79%. HFSYH SURVEYS This paper reports data from the HFSYH surveys. The baseline data for this program were collected in 1999. The initial 2002 survey data are reported here and compared with both the HFSYH 1999 baseline data and to the data in the HP 2010 report. The purpose of the survey is to document current knowledge, attitudes, and self-reported practices of consumers to track the success of public food safety education programs.

Journal of THE AMERICAN DIETETIC ASSOCIATION / 1115

BEYOND THE HEADLINES Survey Background and Analysis Harris Interactive, Inc. (Rochester, NY) collected data for the HFSYH survey by a national (United States) telephone survey from September 3, 2002, through September 10, 2002, using a random digit dialing technique that reduced serial bias and ensured that individuals with listed, as well as unlisted, telephone numbers were included in the survey. The 1,006 qualified study respondents were heads of households between the ages of 20 and 75 years with total annual incomes over $20,000 who prepared the main meal for the household three or more days per week. Questions focused on food safety knowledge, attitudes toward food safety, food safety behaviors of consumers at home, and access to food safety information. The margin of error for the survey was ⫾3.1%. The 1999 HFSYH baseline survey conducted by Yankelovich Partners, Inc. (Norwalk, CT), following the same parameters, included 1,000 respondents. The demographic data for the two surveys were similar (Table 1). Results are reported as frequencies, and all statistical comparisons between the two survey periods were made using two-tailed Fisher exact tests, with significance set at P⬍.05. General Food Safety Knowledge In free response to the question, “When food is prepared at home, what do you think are the most common things that people do that might cause food poisoning,” respondents named inadequate cleaning and sanitation (61%), improper refrigeration (49%), undercooking (26%), cross contamination (18%), improper food storage (12%), and consuming food that is spoiled (6%) as the major food safety issues for home-prepared food. In a more structured question asking specifically about food handling practices, respondents confirmed their free responses (Table 2). The only significant response change over the three-year period between the HFSYH baseline survey and the 2002 survey was that the numbers of respondents who found those practices related to refrigeration of foods “extremely likely” or “very likely” to cause foodborne illness were lower than those of the 1999 HFSYH benchmark survey (P⫽.03). Although 35% of the respondents reported that they knew the temperature food safety experts recommend for cooking ground beef, only 9% gave the correct temperature (160°F) on further questioning. Although adult consumers exhibited 1116 / September 2003 Volume 103 Number 9

Table 1 Demographic data Characteristic

2002 (%) Nⴝ1,006

1999 (%) Nⴝ1,000

Age (y) 20-24 25-29 30-34 35-39 40-49 50-64 65-75

5 8 13 10 26 27 11

7 9 13 14 26 22 10

Gender Male Female

35 65

30 70

Marital status Married Single, never married Divorced/separated Widowed

67 16 13 4

68 17 10 5

Education Eighth grade or less Some high school High school graduate Some college College graduate Postgraduate study

1 3 24 28 26 19

1 4 28 26 26 16

Household income ($) 20,000⬍35,000 35,000⬍50,000 50,000⬍75,000 75,000⬍100,000 100,000 or more Refused/not sure

21 22 21 13 15 8

29 23 22 10 8 8

Children under 18 years of age in household None 1 2 3 or more

54 18 19 9

53 18 17 13

Race White African American Asian or Pacific Islander Native American Other/refused Hispanic Origin

83 6 2 1 8 6

84 7 1 1 6 5

Region Northeast Midwest South West

18 33 26 23

DNA DNA DNA DNA

37

46

34

29

29

26

21 79

21 78

Responsible for meal preparation in household Always (7 d/wk) Most of the time (5-6 d/wk) Some of the time (3-4 d/wk) Anyone in household on medically restricted diet Yes No DNA⫽Data not available.

general knowledge of factors that affect foodborne illness, there were large gaps in their knowledge bases, especially on specific recommendations. For example, in the 2002 HFSYH survey, on specific questioning, 68% recognized that undercooking meat could cause foodborne illness, but only 26% gave this factor in free response, and only 9% could give the correct internal temperature endpoint for cooking ground beef. Data from the HFSYH survey supported the work of other studies in showing that these knowledge gaps included all areas covered in national food safety awareness programs, including “cook,” “chill,” “clean,” and “separate” (22,23,26,28,3033,37). These knowledge gaps are important because they may lead to development and implementation of inappropriate behaviors. Also, although knowledge alone does not change behavior, knowledge makes it possible for the consumer to make more informed choices. For these reasons, these knowledge gaps are barriers to establishing appropriate food safety behaviors (9-11,17,19,3032,35-37,41). Participants Views of Food Safety Respondents generally did not think that it is extremely common or very common for people in the United States to become sick because of the way food is handled or prepared in their homes (70%), and most (60%) did not associate symptoms such as fever, chills, and nausea to food prepared at home. Respondents recognized the roles in the food safety chain for persons who prepare food at home (97%), restaurants (96%), supermarkets (95%), food processors or manufacturers (93%), and farms where food is grown (88%). The responsibility of government inspection for ensuring food safety was not included in this survey. Most participants (82%) responded that it is “extremely important” or “very important” to have information that helps them to take control of safety of foods prepared in their homes. Of those with children under 18 years of age at home, only 36% felt that their children know as much as they would like for them to know about home food safety. When asked to rate their food safety behaviors on a scale of A to F, most consumers (85%) gave themselves “A” or “B” grades. The only finding that has changed since the benchmark HFSYH survey in 1999 is the perception that food prepared at home can make you sick, which has decreased from 34% re-

BEYOND THE HEADLINES

Table 2 Comparison of 2002 with 1999 benchmark survey data on consumer responses to questions on the relationship between food handling and foodborne illness: “How likely is it that you would experience food poisoning if food you ate was handled in that way?” Itema

Extremely/very likely (%)

Forgetting to wash your hands before beginning to cook (P⫽.08) Not washing your hands after touching raw meat or chicken and then touching vegetables that will be eaten raw (P⫽.72) Not washing a cutting board in between using it to cut raw meat or chicken then using the same board to cut vegetables that will be eaten raw (P⫽.69) Serving cooked meat on a plate that was used to hold meat when it was raw (P⫽.86) Eating meat or chicken that is not cooked to a proper temperature (P⫽.71) Eating food that was left out of the refrigerator for more than 2 hours (P⫽.03) Eating food that was stored in a refrigerator whose temperature is set to higher than 40 degrees (P⫽.03) a

Not very/not at all likely (%)

2002 Nⴝ1,006

1999 Nⴝ1,000

2002 Nⴝ1,006

1999 Nⴝ1,000

42

45

17

15

66

70

7

7

73

78

6

5

68

72

7

8

68

74

6

6

42

48

14

12

44

46

16

12

P values are for the difference in 1999 and 2002 responses.

sponding in 1999 that it is “extremely common” or “very common” to 28% responding in those categories in 2002 (P⫽.01). Although consumers recognized that persons who prepare food at home have major responsibility for food safety in their households and think that they and their children need information on food safety to take control of food safety in their homes, they do not appear to find problems with current home food safety behaviors. This implies that consumers find current home food safety behaviors sufficient to maintain their health. Fein and colleagues (31) reported that only 17% of their respondents linked foodborne illness with home food-handling practices. In the 2002 HFSYH survey, 28% of respondents found it “extremely common” or “very common” for people to become sick because of home foodhandling practices, down from 34% in the 1999 HFSYH benchmark survey. Additionally, most respondents gave themselves high marks for their own food safety behaviors. Based on health belief models, these attitudes of low risk and high control will lead to less action and will make it harder for educators to reach consumers with appropriate information (31,35,36,41). Self-Reported Behaviors Except for inadequate use of meat thermometers and infrequent changing of cleaning implements, most consumers reported following recommended food sanitation and handling practices most or all of the time (Table 3). However,

only 14% of the survey participants reported following all of the recommended behaviors all or almost all of the time (Table 4). Another 46% of participants reported following all but one of the recommended behaviors all or almost all of the time; the most common recommended behavior that was not followed by these participants was cooking (81%), followed by separation (16%) (Table 4). Individuals who reported that they did not prepare/eat meat, poultry, or fish were not included in these data on following all key food safety practices because many of the questions about the behaviors related to handling these foods. Eleven percent of respondents reported that they or someone in their household had food poisoning as a result of food that was prepared or eaten at home. Although 14% of respondents in those households reported making no changes in their cleaning or food-handling practices, most reported making some changes (Table 5). Consumers generally reported that they spent more effort in cleaning activities following the suspected foodborne illness of a household member. Notably, during the interval from 1999 to 2002, respondents indicated that they were cooking foods more thoroughly. In general, fewer respondents reported making changes to their cleaning and food-handling practices in 2002 than in 1999. Responses from the HFSYH surveys are similar to those from other national surveys that have asked consumers questions about specific behaviors as indicators of their overall food safety be-

haviors. Although there are differences in actual percentages, the percentages are generally above 75% for following recommended procedures for “clean,” “chill,” and “separate” (21,22,25-27,34, 37). The typical indicator used for “clean” across many surveys is hand washing before food preparation. In the HFSYH surveys, consumers reported washing their hands before food preparation at least 90% of the time (Table 3). This is comparable with other survey reports of 80% to 93% (21,26,27,34). Also, consumers recognized the importance of hand washing in reducing food safety risk (Table 2) and reported that they washed their hands more frequently when they suspected an incidence of foodborne illness in their own household (Table 5). Based on these survey data and data from other surveys, consumers recognize the value of hand washing in reducing risk of foodborne illness. These survey data do not assess whether consumers wash their hands following recommended procedures. “Chill” is typically described by the amount of time perishable food is left unrefrigerated. In the HFSYH surveys, 86% of respondents reported that they refrigerate perishable foods within the recommended two hours (Table 3). Bruhn and Schultz (37) reported that almost half of consumers think that cooked food should be cooled at room temperature before refrigerating it. This does not preclude refrigeration within the recommended two hours, although the general recommendation would be to refrigerate

Journal of THE AMERICAN DIETETIC ASSOCIATION / 1117

BEYOND THE HEADLINES

Table 3 Comparison of 2002 with 1999 benchmark survey data on consumer responses to questions on food-handling behaviors Question and responsesa

2002 (%) Nⴝ1,006

1999 (%) Nⴝ1,000

90 10

91 9

1 10 2 86 1

1 14 2 83 1

? After cutting raw meat, raw chicken, or raw fish, do you (Pⴝ.15) Continue to use the surface you used to cut the raw meat, chicken or fishc Rinse or wipe the surface you usedc Wash the surface with soap and waterb Wash the surface with soap and bleachb Don’t cook with meat, chicken, or fish

1 9 70 18 1

1 11 69 16 1

How often do you use different plates for handling raw meat and cooked meat? (Pⴝ.82) Always/most of the timeb Rarely/neverc

84 10

85 10

How often do you not wash utensils used to handle raw food before they are used for cooked foods? (Pⴝ.77) Always/most of the timec Rarely/neverb

18 78

18 78

How often do you use the same cutting board without cleaning it with hot soapy water between using it for raw meat or chicken and using it for read-to-eat food? (Pⴝ.04) Always/most of the timec Rarely/neverb

13 83

10 86

How often do you use a meat thermometer to check the doneness for red meat, pork, or poultry? (Pⴝ.01) Always/most of the timeb Rarely/neverc

25 57

22 65

How often do you leave perishable food out of the refrigerator for more than 2 hours? (Pⴝ.51) Always/most of the timec Rarely/neverb

3 86

3 87

How often do you usually change or replace the sponge, cloth, or rag that you use to clean your kitchen? Every day/several times per week Several times per week Every week Every month Less often than that I use paper towels

29 27 22 14 4 4

29 31 21 12 2 3

Before each time you begin to prepare food in your kitchen, how often do you wash your hands with soap and warm water for at least 20 seconds? (Pⴝ.59) All/Most of the Timeb Some of the Time/Rarelyc After handling raw meat, raw chicken, or raw fish, do you (Pⴝ.03) Continue cookingc Rinse hands with waterc Wipe hands offc Wash hands with soap and waterb Don’t cook with meat, chicken, or fish

?

a

P values are for the differences between 1999 and 2002 in following recommended behaviors (all behaviors self reported). Recommended behavior. c Behavior not recommended. b

the food more rapidly. Although consumer reports of following this behavior are stable over the period from 1999 to 2002 and respondents reported being more careful to follow this behavior if they suspected a case of foodborne illness in their own households, their appreciation of its value is decreasing (Ta1118 / September 2003 Volume 103 Number 9

ble 2). The indicators of following this behavior effectively, having a refrigerator thermometer (42%) and knowing the temperature of the refrigerator setting (39%), are met by fewer respondents than those who report practicing the recommended behavior. These relatively low values do not validate the reported

consumer behaviors. Three percent of respondents would have met all food safety behaviors recorded in the HFSYH surveys all or almost all of the time if they had followed the recommendation to refrigerate perishable foods within two hours. “Separate” describes reducing crosscontamination of potential pathogens from raw foods to ready-to-eat foods. This behavior was assessed using five questions: two questions that gave consumers choices of behaviors and three questions that assessed their responses to using the recommended behaviors (Table 3). Seventy-eight percent to 86% of respondents reported using recommended behaviors for individual questions in this category (Table 3), which generally compares with the 68% to 93% reported in other surveys for these behaviors (21,23,25-27,34,37). In 2002, more consumers reported washing their hands with soap and water after handling raw meat, raw chicken, or raw fish than during the FSYH 1999 benchmark survey (P⫽.03). Although there was no difference in the 2002 and 1999 survey responses for the cross-contamination question on the method for treating the cutting board after cutting raw meat, chicken, or fish (P⫽.15), fewer respondents in the 2002 survey responded that they “rarely” or “never” use the same cutting board without cleaning it with hot soapy water between using it for raw meat or chicken and using it for ready-toeat food (P⫽.04). Additionally, over two thirds of respondents recognized the importance of preventing cross-contamination in reducing risk of foodborne illness (Table 2). Fewer people reported improving on this behavior following a suspected case of foodborne illness in their household in the 2002 survey than in the 1999 survey (Table 5), but that might be because they felt they were already following recommended practices in this area. Of the four categories of behaviors, “separate” was second to “cook” in the number of individuals missing only one category of behaviors to follow all recommended food safety behaviors all or most of the time (Table 4). The single indicator for “cook” behaviors was using a thermometer to measure internal temperatures of cooked flesh foods. Although over two thirds of respondents recognized that eating meat that is not cooked thoroughly can increase risk of foodborne illness (Table 2) and 12% report more thorough cooking after a suspected case of foodborne ill-

BEYOND THE HEADLINES

Table 4 Participants following all and all except one of the key food safety practices all or most of the time Followed key food safety practices—HFSYH 2002a

Population

Reported following all positive behaviors all or most of the time, except those in this category (%)b Nⴝ448

Reported following all positive behaviors all or most of the time (%)b Nⴝ982

Cookc

Cleand

Chille

Separatef

Total

14

81

0

3

16

Race and ethnicity Native American Asian or Pacific Islander African American White Hispanic origin

DSU DSU 5 15 10

DSU DSU 89 81 70

DSU DSU 0 1 0

DSU DSU 0 3 7

DSU DSU 11 16 20

Gender Female Male

15 13

81 81

0 1

4 1

15 17

Family income (annual) Less than $10,000 $10,000-$19,999 $20,000 and above

DNC DNC 14

DNC DNC 81

DNC DNC 0

DNC DNC 3

DNC DNC 16

Education level Less than high school High school graduate At least some college

9 13 15

76 73 84

0 1 0

0 3 3

24 23 13

Disability status Persons with disabilities Persons without disabilities

DNC DNC

DNC DNC

DNC DNC

DNC DNC

DNC DNC

DNC

DNC

DNC

DNC

DNC

DNC 13 16 20 13

DNC 81 80 76 82

DNC 1 0 1 0

DNC 3 2 2 3

DNC 15 18 21 15

Select populations Children under 5 years of age in household No children under 5 years of age in household 20-49 years of age 50-75 years of age Medically restricted diet in household No medically restricted diet in household

HFSYH⫽Home Food Safety . . . It’s in Your Hands. DSU⫽Data are statistically unreliable. DNC⫽Data are not collected. a Key food safety practices are based on the four FightBAC! Campaign messages: clean—wash hands and surfaces often; separate— don’t cross-contaminate; cook— cook to proper temperatures; and chill—refrigerate promptly. b Excludes those who never eat meat, poultry, or seafood. c Based on response to the question: “How often do you use a meat thermometer to check the doneness for red meat, pork, or poultry?” A positive response is all or almost all of the time. d Based on response to the question: “Before each time you begin to prepare food in your kitchen, how often do you wash your hands with soap and warm water for AT LEAST 20 seconds?” A positive response is all or almost all of the time. e Based on response to the question: “How often do you leave perishable food out of the refrigerator for more than 2 hours?” A positive response is rarely or never. f Based on positive responses to three questions: “How often do you use different plates for handling raw meat and cooked meat” (positive response all or most of the time), “How often do you not wash utensils used to handle raw food before they are used for cooked foods” (positive response rarely or never), and “How often do you use the same cutting board without cleaning it with hot soapy water between using it for raw meat or chicken and using it for ready-to-eat food” (positive response rarely or never).

ness in their household (Table 5), only 25% report using a thermometer to validate cooking processes for flesh foods (Table 3). Eighty-one percent of individuals who reported meeting all but one of the recommended behaviors most or all of the time did not meet this behavior. Although cleaning (clean), avoiding cross-contamination (separate), and storing perishable food in the refrigerator (chill) reduce the potential for con1120 / September 2003 Volume 103 Number 9

tamination of food and bacterial growth on potentially hazardous foods, only appropriate cooking inactivates pathogens in foods that individuals prepare for themselves and their households. HFSYH data show that more individuals self reported using thermometers in 2002 than in 1999 (P⫽.01); however, this category has by far the lowest percentage of respondents reporting following recommended behaviors of all of the food

safety behavior categories (Table 3). This is important because, although consumers may use other indicators of doneness, such as recipe cooking times and visual cues to assess safety, these indicators do not accurately validate cooking processes (42). Although use of a thermometer to measure doneness in meat has been recommended for many years, actual recommendations that temperature and not visual cues be used to en-

BEYOND THE HEADLINES

Table 5 Comparison of 2002 with 1999 benchmark survey data on changes in food-handling practices as a result of self-reported foodborne illness in the home Responses (multiple responses permitted; only individuals who responded that someone in their household had food poisoning as a result of food prepared or eaten at home are included)

2002 (%) Nⴝ113

1999 (%) Nⴝ116

Not leaving perishable food out of the refrigerator for more than 2 hours Practiced washing hands frequently Increased the amount of time spent cleaning/sanitizing kitchen foodhandling surfaces Increased cooking time/cook food thoroughly Using separate cutting boards for handling raw meat and raw fruits and vegetables Increased the amount of time spent cleaning/sanitizing kitchen food containers Increased the amount of time spent cleaning/sanitizing kitchen sponges/cloths more frequently Using a meat thermometer Practiced changing kitchen sponges/cloths more frequently Using a thermometer in the refrigerator Did not change food handling practices Other (unnamed)

16 14

16 15

14 12

17 0

4

11

3

10

2 2 1 0 14 39

6 2 4 3 13 54

sure safety of meat began in 1997 (19), making this recommendation a new one for consumers. Based on the HFSYH survey, this behavior offers the most opportunity for positive food safety behavior change in the US population. Based on the health belief model, consumers may be ready to make this change; 70% of individuals who changed their hamburger preferences to more well-done did so because of safety concerns (19). Survey Methodology Limitations in Assessing Behaviors As a methodology, all surveys have limitations in assessing behaviors. The surveys are not validated by checking actual consumer behaviors, ie, whether recom-

Table 6 Comparison of 2002 with 1999 benchmark survey data on sources of food safety information Source

2002 (%) Nⴝ1,006

1999 (%) Nⴝ1,000

Television Radio Newspapers or magazines Friends and family Internet American Dietetic Association Government or government hotlines Companies or company hotlines

57.7 28.7

62.2 21.4

66.3 48.1 26.6

66.2 45.6 16.1

21.9

13.8

18.2

14.0

12.3

10.0

mended hand-washing techniques were followed or whether thermometers were used correctly. Also, for knowledgeable consumers, giving the “correct” answer shows their response to social norms, whether or not they followed the specific behavior appropriately. At the very least, however, the high percentage of responses to questions on “chill,” “separate,” and “clean” show that consumers know the messages related to the specific behaviors included on the HFSYH questionnaires. The small number of questions used to assess each behavior limits results of current food safety surveys, including the HFSYH surveys, to assess behaviors. The best-assessed behavior in the HFSYH survey is “separate,” which included five behavior questions. Only one question each was included to assess behaviors for the areas of “clean,” “cook,” and “chill.” Including multiple questions for “clean,” “cook,” and “chill” in future surveys, as they were for “separate” in the current HFSYH surveys, will provide stronger evidence for assessing consumer behaviors. Access to Food Safety Information The primary sources of food safety information continue to be traditional media (Table 6), although Internet use for locating food safety information is growing. Friends and family continue to be important sources of food safety information. The ADA is perceived as a source of food safety information more frequently than are government agencies, companies, or their hotlines. Except for television, respondents report more use

of every source of food safety information in the 2002 survey compared with the 1999 benchmark HFSYH survey. Additionally, 95% of respondents reported that they think that “it is important for leading companies to provide information to the public about important issues such as food safety,” and 62% of respondents would find restaurant-provided food safety instructions for the proper reheating and storage of leftovers “extremely helpful” or “very helpful.” Data from the 2002 HFSYH survey are compatible with the research of Bruhn and Schultz (37), which described health professionals as reliable sources of food safety information (89% of respondents). The Bruhn-Schultz survey also described government publications (76%), newspapers (65%), friends and family (56%), television programming (74%), and television news (59%) as reliable sources of food safety information. These information sources were all reported as sources of information in both the 1999 and 2002 HFSYH surveys. Additionally, it is clear that individuals are actively seeking information about food safety through personal searches on the Internet and queries to the ADA, government agencies, or companies. Although access to media sources of food safety information is likely to be more passive than these personal searches for information, consumers reported continued exposure to food safety information through traditional media. Their improved behaviors in food handling and sanitation may, in part, reflect the consistency of repeated exposures to the four public health food safety messages: “chill,” “cook,” “clean,” and “separate.” Many of the media sources depend on experts from the ADA, government, and companies to provide reliable, research-based information. This information is structured to show the public how to apply this information to their personal needs. Therefore, in many cases, the media represents the “long arms” of those organizations and their food safety education programs. The HFSYH survey data show that consumers do not typically remember details, such as recommended internal temperatures for cooked flesh foods or recommended refrigerator temperatures. Also, the respondents supported having restaurants include information on holding and heating leftovers, increasing access to information when it is needed. Although education on basic concepts can help consumers under-

Journal of THE AMERICAN DIETETIC ASSOCIATION / 1121

BEYOND THE HEADLINES

Table 7 Comparison of Healthy People 2010 (HP 2010) baseline data and Food Safety . . . It’s in Your Hands (HFSYH) 2002 survey data Followed key food safety practicesa

Population HP 2010 baseline (%)b

HFSYH 2002 (%)c Cookd

Cleane

Chillf

Separateg

Total

72

25

90

86

82

Race and ethnicity Native American Asian or Pacific Islander African American White Hispanic origin

DSU DSU 70 73 DSU

DSU DSU 10 26 30

DSU DSU 90 90 90

DSU DSU 80 88 71

DSU DSU 75 83 83

Gender Female Male

75 69

26 23

92 86

85 87

84 78

Family income (annual) Less than $10,000 $10,000-$19,999 $20,000 and above

DSU 72 72

DNC DNC 25

DNC DNC 90

DNC DNC 86

DNC DNC 82

Education level Less than high school High school graduate At least some college

DSU 74 72

DNA DNA DNA

DNA DNA DNA

DNA DNA DNA

DNA DNA DNA

Disability status Persons with disabilities Persons without disabilities

DNC DNC

DNC DNC

DNC DNC

DNC DNC

DNC DNC

Select populations Children under 5 years of age in household No children under 5 years of age in household 18-59 yearsh 60 years and olderh Medically restricted diet in household No medically restricted diet in household

72 73 72 75 DNC DNC

DNC DNC 23 29 33 23

DNC DNC 88 92 90 90

DNC DNC 85 87 84 86

DNC DNC 82 81 83 82

DSU⫽Data are statistically unreliable. DNC⫽Data are not collected. DNA⫽Data not analyzed. a Key food safety practices are based on the four FightBAC! Campaign messages: clean—wash hands and surfaces often; separate— don’t cross-contaminate; cook— cook to proper temperatures; and chill—refrigerate promptly. b Adjusted to 1993 census proportions on gender, race, and education. HP 2010 baseline data are from reference 40. c Followed recommended practice all or most of the time. d Based on response to the question: “How often do you use a meat thermometer to check the doneness for red meat, pork, or poultry?” e Based on response to the question: “Before each time you begin to prepare food in your kitchen, how often do you wash your hands with soap and warm water for AT LEAST 20 seconds?” f Based on response to the question: “How often do you leave perishable food out of the refrigerator for more than 2 hours?” g Based on the mean percentage response to three questions: “How often do you use different plates for handling raw meat and cooked meat,” “How often do you not wash utensils used to handle raw food before they are used for cooked foods,” and “How often do you use the same cutting board without cleaning it with hot soapy water between using it for raw meat or chicken and using it for ready-to-eat food.” h There is a slight difference in reporting for this category. HFSYH age groups were 20-49 (18-59 years for HP 2010) and 50-75 years (60 years and older for HP 2010).

stand the importance of following effective food safety behaviors, easy access to specific information, such as internal temperature charts for different meats, supports implementation of effective behaviors. Consumers reported that they want food safety information for themselves and their children, making it likely that they will use information when it is available and when they think it is applicable to their needs. COMPARISON OF HFSYH RESPONSES TO HP 2010 DATA Comparisons with the HP 2010 baseline data (40) are in Table 7. Although HP 1122 / September 2003 Volume 103 Number 9

2010 reports a mean value across the major food safety behaviors, the HFSYH data are reported for the individual behaviors. Most categories are congruent, but the age category is reported differently in the HFSYH survey from the HP 2010 data. The HFSYH data include breakout responses for households with individuals on medically restricted diets, but the HP 2010 data do not. The mean scores across all behavior categories for the total population in HFSYH is 71%, almost the same as the HP 2010 baseline value of 72%; however, all of the categories except “cook” were well above the HP 2010 target of 79%. The self-reported

behaviors for “chill,” “clean,” and “separate” were well above the HP 2010 target of 79% for each racial/ethnic, gender, and age grouping, except that “separate” was 75% for African Americans and “chill” was 71% for Americans of Hispanic origin. For the total sample, only 25% reported following the recommendation to use a food thermometer to judge doneness of meat, poultry, and fish (“cook”); no racial/ethnic, gender, or age grouping exceeded 30% for following this recommendation, but 33% of re spondents from households that included an individual on a medically restricted diet reported following this

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BEYOND THE HEADLINES recommendation “always” or “most of the time.” Although the reported HP 2010 baseline value across the key behaviors of 72% is comparable with the HFSYH mean value of 71%, it does not discriminate among the behaviors well. HFSYH data show that, for the sample populations represented, consumers generally self reported that they are following recommended food safety behaviors for “chill” (86%), “clean” (90%), and “separate” (82%) at levels that exceed the HP 2010 target of 79% compliance (40). However, HFSYH data clearly show that most consumers (75%) do not report using a thermometer to measure the internal temperature of meat, poultry, or fish. Better data on “cook” indicators are needed to validate the HFSYH findings because food may be cooked to appropriate temperatures, even though consumers do not validate the cooking process. The HP 2010 baseline data could be better presented to help health professionals select targets for their food guidance messages. CONCLUSION Dietitians can improve their clients’ long-term health by translating food safety knowledge and skills into food guidance for their clients. One message to include in this guidance is the appropriate use of thermometers to validate the cooking process for flesh foods. This is important because cooking destroys pathogens that cause foodborne illness, and few consumers report following the recommendations that validate appropriate cooking. In general, effective education programs increase knowledge to give a base for recommended behaviors, improve motivation to perform recommended behaviors by showing their importance to the individual, and provide training on performing recommended behaviors correctly. The knowledge of “what,” the motivation of “why,” and the training for “how” are integrated in effective education programs to improve daily practices and reduce personal and household risk. It is especially important that those at highest risk be effectively educated and that their education be assessed because their clinical outcomes can be affected by their foodhandling and sanitation behaviors. In some areas of clinical practice, food safety is already given in the standard of practice (9,11). In others, where current knowledge emphasizes client 1124 / September 2003 Volume 103 Number 9

risk (8,13), forward-thinking practitioners will include food safety education in their local clinical practice guidelines. Dietitians are the only members of the health-care team who have the knowledge base to translate food safety knowledge and skills into food guidance for their clients. Failure to provide effective food safety education, when it is clearly indicated by clinical condition, may become the basis for malpractice claims if a client develops a lethal or debilitating foodborne illness after dietetic consultation. References 1. Mead PS, Slutsker L, Dietz V, McCaig LF, Bresee JS, Shapiro C, Griffin PM, Tauxe RV. Foodrelated illness and death in the United States. Emerg Infect Dis. 1999;5:607-625. 2. Potter ME, Tauxe RV. Epidemiology of foodborne diseases: Tools and applications. World Health Stat Q. 1997;50:24-29. 3. Altekruse SF, Cohen MI, Swerdlow DL. Emerging foodborne diseases. Emerg Infect Dis. 1997;3: 285-293. 4. Olsen SJ, MacKinon LC, Goulding JS, Bean NH, Slutsker L. Surveillance for Foodborne Disease Outbreaks—United States, 1993-1997. MMWR. 2000;49:1-51. 5. Centers for Disease Control and Prevention. Preliminary FoodNet Data on the Incidence of Foodborne Illnesses—Selected Sites, United States, 2002. MMWR. 2003;52:340-343. 6. Environmental Protection Agency, United States Department of Agriculture, Center for Food Safety and Applied Nutrition of the Food and Drug Administration, Division of Nutrition Research Coordination for the National Institutes of Health, CDC. Achievements in public health, 1900-1999: Safer and healthier foods. MMWR. 1999;48:905913. 7. United States Department of Agriculture, Economic Research Service. Economics of foodborne disease. Available at: http://www.ers.usda.gov/ briefing/FoodborneDisease. Accessed July 3, 2003. 8. Helms M, Vastrup P, Gerner-Schmidt P, Molbak K. Short and long term mortality associated with foodborne gastrointestinal infections: Registrybased study. Brit Med J. 2003;326:357-361. 9. Kaplan JE, Masur H, Holmes KK. Guidelines for preventing opportunistic infections among HIV-infected persons—2002: Recommendations of the US Public Health Service and the Infectious Diseases Society of America. MMWR. 2002;51:1-46. 10. American Medical Association, Center for Food Safety and Nutrition of the Food and Drug Administration, Food Safety and Inspection Service of the US Department of Agriculture. Diagnosis and management of foodborne illnesses: A primer for physicians. MMWR. 2001;50:1-69. 11. Dykewicz CA, Jaffe HW, Kaplan JE. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients: Recommendations of CDC, the Infectious Disease Society of America, and the American Society of Blood and Marrow Transplantation. MMWR. 2000; 49:1-128. 12. Plaut AG. Clinical pathology of foodborne diseases: Notes on the patient with foodborne gastrointestinal illness. J Food Protect. 2000;63:822826. 13. Smith JL. Campylobacter jejuni infection dur-

ing pregnancy: Long-term consequences of associated bacteremia, Guillain-Barre syndrome, and reactive arthritis. J Food Protect. 2002;65:696708. 14. LaBudde RA. Guest editorial: Why consumers take risks. Food Safety Mag. 2003;9:14-17. Available at: http://www.foodsafetymagazine.com/ issues/0304/colguested0304.htm. Accessed June 4, 2003. 15. Kohl KS, Rietberg K, Wilson S, Farley TA. Relationship between home food-handling practices and sporadic salmonellosis in adults in Louisiana, United States. Epidemiol Infect. 2002;129: 267-276. 16. United States Food and Drug Administration Center for Food Safety & Applied Nutrition. Foodborne pathogenic microorganisms and natural toxins handbook. Available at: http://www.cfsan. fda.gov/⬃mow/intro.html. Accessed June 4, 2003. 17. Medeiros LC, Hillers VN, Kendall PA, Mason A. Food safety education: What should we be teaching to consumers? J Nutr Educ. 2001;33:108-113. 18. Knabel SJ. Foodborne illnesses: Role of home food handling practices. Food Technol. 1995;49: 119-131. 19. Ralston K, Brent CP, Starke Y, Riggins T, Lin CTJ. Consumer Food Safety Behavior: A Case Study in Hamburger Cooking and Ordering. ERS Agricultural Economic Report No. AER804. May 2002:33. 20. Lindsay JA. Chronic sequelae of foodborne disease. Emerg Infect Dis. 1997;4:443-452. 21. Shiferaw B, Yang S, Cieslak P, Vugia D, Marcus R, Koehler J, Deneen V, Angulo F. Prevalence of high-risk food consumption and food-handling practices among adults: A multistate survey, 1996-1997. The FoodNet Working Group. J Food Prot. 2000;63:1538-1543. 22. Altekruse SF, Street DA, Fein SB, Levy AS. Consumer knowledge of foodborne microbial hazards and food-handling practices. J Food Prot. 1996;59:287-294. 23. Jay LS, Comar D, Govenlock LD. A national Australian food safety telephone survey. J Food Prot. 1999;62:921-928. 24. Yang S, Angulo FJ, Altekruse SF. Evaluation of safe food-handling instructions on meat and poultry products. J Food Prot. 2000;63:1321-1325. 25. Li-Cohen AE, Bruhn CM. Safety of consumer handling of fresh produce from the time of purchase to the plate: A comprehensive consumer survey. J Food Prot. 2002;65:1287-1296. 26. Altekruse SF, Yang S, Timbo BB, Angulo FJ. A multi-state survey of consumer food-handling and food-consumption practices. Am J Prev Med. 1999;16:216-221. 27. Yang S, Leff MG, McTague D, Horvath KA, Jackson-Thompson J, Murayi T, Boeselager GK, Melnik TA, Gildemaster MC, Ridings DL, Altekruse SF, Angulo FJ. Multistate surveillance for foodhandling, preparation, and consumption behaviors associated with foodborne diseases: 1995 and 1996 BRFSS food-safety questions. MMWR/CDC Surveill Summ. 1998;47:33-57. 28. Redmond EC, Griffith CJ. Consumer food handling in the home: A review of food safety studies. J Food Prot. 2003;66:130-161. 29. Herrmann RO, Warland RH. Awareness of an unfamiliar food safety hazard: Listeria 1999. Consum Interests Ann. 2000;46:1-6. 30. Endres J, Welch T, Perseli T. Use of a computerized kiosk in an assessment of food safety knowledge of high school students and science teachers. J Nutr Ed. 2001;33:37-42. 31. Fein SB, Jordan-Lin CT, Levy AS. Foodborne illness: Perceptions, experiences and preventative

BEYOND THE HEADLINES behaviors in the United States. J Food Prot. 1995; 58:1405-1411. 32. Sammarco ML, Ripabelli G. Consumer attitude and awareness towards food related hygienic hazards. J Food Safety. 1997;17:215-221. 33. Collins JA. Impact of changing consumer lifestyles on the emergence/reemergence of foodborne pathogens. Emerg Infect Dis. 1997;4:471479. 34. Klontz KC, Timbo B, Fein S, Levy A. Prevalence of selection, food consumption and preparation behaviors associated with increased risks of food-borne disease. J Food Prot. 1995;58:927930. 35. Bruhn CM. Consumer concerns: Motivating to action. Emerg Infect Dis. 1997;4:511-515. 36. Gettings MA, Kiernan NE. Practices and perceptions of food safety among seniors who pre-

pare meals at home. J Nutr Ed. 2001;33:148154. 37. Bruhn CM, Schultz HG. Consumer food safety knowledge and practices. J Food Safety. 1999;19: 73-87. 38. American Dietetic Association and ConAgra Foods Foundation Home Food Safety . . . It’s in Your Hands. Available at: http://www.homefoodsafety.org. Accessed July 3, 2003. 39. The Partnership for Food Safety Education. FightBAC! Available at: http://www.fightbac.org/ main.cfm. Accessed July 3, 2003. 40. US Department of Health and Human Services. Healthy People 2010: Vol. I. Objectives for Improving Health (Part A): Food Safety, November 2000:10:1-18. Available at: http://www.healthypeople.gov/Document/pdf/Volume1/10Food.pdf. Accessed June 4, 2003.

41. Schafer RB, Schafer E, Bultena G, Hoiberg EO. Food safety: An application of the health belief model. J Nutr Edu. 1993;25:17-24. 42. United States Department of Agriculture Food Safety Inspection Service. Doneness versus safety. May 2000. Available at: http://www.fsis. usda.gov/OA/pubs/doneness.htm. Accessed June 6, 2003.

The authors gratefully acknowledge the support of the ADA/ConAgra Foods Home Food Safety . . . It’s in Your Hands program for conducting the consumer surveys and providing the authors with data for the paper.

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