EAL

FNOA: Aging Programs (2012)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To study the effects of an educational intervention on improving home food safety practices in older adults.

Inclusion Criteria:

Adults aged 58 and older from 12 of 13 senior centers in Northeast Georgia.

Exclusion Criteria:

Inability to answer questions and to participate in educational activities as determined by interviewer assessment.

Description of Study Protocol:

Recruitment

A random sample of older adults age 58 and older from 12 of 13 senior centers. This study is part of a larger study with sample recruitment and pre-test (June through August 2004), intervention (three lessons at senior centers, one time per month, November 2004, February 2005 and April 2005) and post-test (May and June 2005).

Design

Before-and-after study.

Intervention

Participation in a home food safety educational program intervention.

Statistical Analysis

A P value of 0.05 or less was considered statistically significant
Descriptive statistics including frequencies, means and standard deviations were calculated. Chi-squared analyses and paired T-tests were used to assess changes in food safety practices after the intervention.
Forward stepwise regression analyses were used to identify barriers to and predictors of practicing the targeted behaviors at the pre-test level and to identify factors associated with making changes in the targeted behaviors after the intervention.

Data Collection Summary:

Timing of Measurements

Pre-test and post-test.

Dependent Variables

Yes/No answers to the following questions:

Home food safety practices that everyone can do:
- Wash your hands with warm water and soap for 20 seconds before eating food?
- Rinse fresh fruits and vegetables with cold running water before eating them?
- Did you avoid eating cookie dough or cake batter that was made with raw eggs?
- Have you checked the temperature of your refrigerator?
Home food safety practices that food preparers can do:
- Clean the countertops before preparing food?
- Rinse fresh fruits and vegetables in cold running water before preparing them?
- Wash your hands with warm water and soap for 20 seconds before preparing food?
- Wash, rinse and sanitize the cutting boards after preparing raw meat, fish and poultry?
- Keep raw meat, fish and poultry wrapped properly in the refrigerator so juices do not drip on other foods?
- Put cooked meat, fish and poultry on a different platter then the one with raw juices?
- Rotate food in the microwave to avoid "cold spots"?
- Bring sauces, soups and gravy to a boil when reheating?
In the past month did you always:
- Make sure eggs were cooked properly?
- Refrigerate leftovers right away?
- Defrost foods in the refrigerator or in cold water or in the microwave?
- Do you have a food thermometer?

Independent Variables

Age
Percentage of women
Percentage Caucasian
Education
Food insecurity
Self-reported diseases including cancer, high blood pressure, diabetes, heart disease and arthritis
Short physical performance battery.

Description of Actual Data Sample:

Initial N: 136 older adults
Attrition (final N): 92 (68% completion)
Age: 79±7 years
Ethnicity: 61% Caucasian
Other relevant demographics: 75% women
Location: Northeast Georgia, US.

Summary of Results:

Key Findings

Self-reported home food safety practices were assessed using a 16-item original questionnaire. Four questions assessed home food safety practices that everyone can do. 12 questions assessed home food safety practices that generally only food preparers can do.
From the 16 individual home food safety practices three summary scores were created:
- Practices that everyone can do
- Practices that food preparers can do
- Total home food safety practices.
The following table shows the changes in home food safety practices from pre-test to post-test:

In the Past Month Did You Always:	Change in Percentage Points	P-Value
Home food safety practices everyone can do:
Wash your hands with warm water and soap for 20 seconds before eating food?	14	0.01
Rinse fresh fruits and vegetables with cold running water before eating them?	5	0.27
Did you avoid eating cookie dough or cake batter that was made with raw eggs?	-4	0.3
Have you checked the temperature of your refrigerator?	10	0.09
Home food safety practices that the food preparer can do:
Clean the countertops before preparing food?	3	0.55
Rinse fresh fruits and vegetables in cold running water before preparing them?	1	0.7
Wash your hands with warm water and soap for 20 seconds before preparing food?	16	0.01
Wash, rinse and sanitize the cutting boards after preparing raw meat, fish and poultry?	5	0.3
Keep raw meat, fish and poultry wrapped properly in the refrigerator so juices do not drip on other foods?	2	0.56
Put cooked meal, fish and poultry on a different platter than the one with raw juices?	8	0.15
Rotate food in the microwave to avoid "cold spots"?	3	0.64
Bring sauces, soups and gravy to a boil when reheating?	3	0.66
Make sure eggs were cooked properly?	0	1
Refrigerate leftovers right away?	1	0.7
Defrost foods in the refrigerator or in cold water or in the microwave?	7	0.28
Use a food thermometer to decide if meat, poultry or fish are done before eating?	7	0.31

An additional question was added to the post-test concerning owning a food thermometer. 65% of participants answered "Yes".
Data analysis showed:
- After the intervention, there was an increase in the number of participants that reported washing their hands with warm water and soap for 20 seconds before eating food and preparing food (P≤0.01)
- There was a non-significant increase in the percentage of participants checking the temperature of their refrigerator (P=0.09)
- There was a significant change in the mean summary score of the summary of all home food safety practices from pre-test to post-test, but no statistically significant changes in the other two mean summary scores
After stepwise regression analysis, several trends were observed among the summary practice scores and characteristics of the participants:
- At pre-test, the most significant finding was that higher age was consistently and significantly associated with lower home food safety practice summary scores
- Higher scores for home food safety practices that everyone can do were significantly associated with lower physical function and having cancer
- Higher scores for home food safety practices that food preparers can do was significantly associated with being food insecure and having arthritis
- Higher summary scores for all practices were non-significantly associated with lower physical function, having arthritis and having cancer
- Higher age was consistently associated with greater changes in all three home safety practice summary scores from pre-test to post-test
- Higher changes in food safety practices that everyone can do was significantly associated with being black rather than white, higher education and not having heart disease
- Greater changes in all food safety practices were significantly associated with not having arthritis.

Other Findings

Other major findings include:

A large variability in adherence to home food safety practices
Checking the temperature of the refrigerator and cooked foods were practiced much less frequently than other practices
Several significant improvements in individual practices and summary scores were found after the intervention
Younger age was the most consistent predictor of adherence to home food safety practices at pre-test
Older age was the most common predictor of improvements after the intervention.

Author Conclusion:

Progress was made in hand washing, both by everyone and by food preparers, but there is still room for additional improvement. Future studies should have a special focus on hand washing since it applies to everyone.
Additional information on the importance of using thermometers and checking temperatures should be provided.
In the future, the questions about food safety practices could be written in a more specific manner.
Overall, the positive outcomes of this study provide evidence that congregate meal program participants can benefit from food, nutrition and wellness education programs that address health promotion and disease prevention.

Funding Source:

Government:	Northwest Georgia Area Agency on Aging, the USDA Food Stamp Nutrition Education Program
University/Hospital:	University of Georgia Agricultural Experiment Station

Reviewer Comments:

The authors note the following limitations:
- The sample size was small
- Outcome data was self-reported
- Attendance at sessions was voluntary
- The sample was primarily women
Blinding was not used in the study.
The reason for withdrawals was not addressed (136 participants took the pre-test but only 92 of the participants took the post-test).

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	Yes
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	Yes
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	Yes
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	Yes

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		???
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	Yes
	2.2.	Were criteria applied equally to all study groups?	N/A
	2.3.	Were health, demographics, and other characteristics of subjects described?	Yes
	2.4.	Were the subjects/patients a representative sample of the relevant population?	???
3.	Were study groups comparable?		N/A
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	N/A
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	N/A
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	N/A
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	N/A
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	N/A
4.	Was method of handling withdrawals described?		No
	4.1.	Were follow-up methods described and the same for all groups?	Yes
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	No
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	No
	4.4.	Were reasons for withdrawals similar across groups?	N/A
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		No
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	N/A
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	No
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	N/A
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		???
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	???
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	N/A
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	Yes
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	Yes
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	No
	6.6.	Were extra or unplanned treatments described?	No
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	N/A
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		Yes
	7.1.	Were primary and secondary endpoints described and relevant to the question?	Yes
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	Yes
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	Yes
	7.5.	Was the measurement of effect at an appropriate level of precision?	Yes
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	???
	7.7.	Were the measurements conducted consistently across groups?	N/A
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	Yes
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
9.	Are conclusions supported by results with biases and limitations taken into consideration?		Yes
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	Yes
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes