EAL

MHFS: Food Safety (2012-2013)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

The purpose of this study was to document current knowledge and perceptions of food safety risk, to probe the likelihood of practicing recommended safe food handling and consumption behaviors and to test an educational strategy designed as a cue to action for food safety interventions.

Inclusion Criteria:

Stem cell transplant (SCT) patient
Organ transplant (OT) patient.

Exclusion Criteria:

Not described.

Description of Study Protocol:

Recruitment

OT patients or family care providers were recruited by flyers posted in the transplant medical unit of a large Midwestern United States comprehensive cancer center and at clinics and locations where transplant support groups met
For the first study examining knowledge and perceptions of food safety risks, physically stable patients were recruited to participate in one of two focus groups held in a conference room in a building contiguous to the medical center
For the second study, both physically-stable and medically-fragile patients were recruited through flyers posted in the cancer center.

Design

Qualitative study.

Statistical Analysis

Quantitative data was analyzed using SPSS
Student's T-tests were used to detect differences between groups for attitude and food preference items
In Study One, ethnographic methods were used to organize responses from the focus groups and interviews into major and minor themes for each sub-group evaluated
For the three sub-groups, a major theme was identified if a topic was raised in both focus groups with OT patients, three of five OT patient interviews and five of 11 SCT patient interviews
A minor theme was identified if the topic was mentioned in one of the OT patient focus groups, two of five OT patient interviews and two to four of 11 SCT patient interviews.

Data Collection Summary:

Timing of Measurements

All patient and family care providers were asked to complete a food safety attitude and food preference questionnaire before the focus group discussion or interview began
The moderator's focus group and interview script for the knowledge and perceptions study were developed with standard procedures
Questions probed the constructs of perceived threat and modifying factors to initiate a behavior according to the Health Belief Model.

Dependent Variables

The survey included demographic and health information items, a 10-item attitudinal scale assessing general attitudes and opinions related to food safety and a seven-item questionnaire on food preference, asking participants if they ate any of a list of foods known to be associated with foodborne illness outbreaks
Knowledge of food safety: Findings from Study One were used to develop educational materials based on the health belief model constructs, perceived threat and modifying factors to behavior action
To assess if the prototypes were viewed by patients as effective cues to action, OT and SCT patients evaluated three educational prototypes in interview settings in the second study
Three prototypes covered foodborne illnesses for immunocompromised individuals, safe food-handling for transplant patients and special precautions needed to reduce risk of listeriosis
Participants were first given time to read each prototype and then to assess the readability, usability, understandability, believability and likability of the educational brochures on a seven-point Likert scale (with 1 being the most negative response and 7 being the most positive response).

Independent Variables

Organ or stem cell transplant patients.

Description of Actual Data Sample:

Initial N: 21 patients (11 organ transplant patients and 10 stem cell patients)
Attrition (final N): 21 patients (11 organ transplant patients and 10 stem cell patients)
Age: Not described
Ethnicity: Not described
Other relevant demographics: Not reported
Anthropometrics: Not reported
Location: Ohio State University.

Summary of Results:

Key Findings

In the first study on knowledge and perceptions of food safety risk, both transplant groups scored high on the food safety attitude scale (OT had a mean score of 31.5 out of 40; SCT had a mean score of 30.5 out of 40; P>0.05)
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
OT patients were generally more likely than SCT patients to consume foods known to be associated with foodborne illness outbreaks
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
Although not different between groups, OT patients showed a propensity to consume items with raw eggs (40% vs. 9%), raw alfalfa sprouts (25% vs. 0%), raw fish-like sushi or ceviche (15% vs. 0%) or cold deli meats (90% vs. 64%). Both groups were somewhat likely to consume cold-smoked fish (30% vs. 27%) and neither group drank unpasteurized milk (0 vs. 0%).
Food-related advice mentioned by patients included the following:
- Avoid fresh fruits and vegetables
- Wash fresh vegetables before eating
- Avoid salad bars or foods prepared by others
- Avoid deli meats, as well as hand-washing, safe food storage, cleaning food surfaces, and cooking food thoroughly.
The major disagreement with the food-safety recommendations involved the advice to reheat deli or lunch meats, as most patients preferred to eat these foods cold or considered it an inconvenience to reheat them
In the second study, Likert-scale responses compared the three prototypes with the foodborne illness and foodborne pathogens brochures receiving the most favorable responses and the brochure on Listeria monocytogenes receiving the next most favorable response
Most patients viewed themselves as susceptible to serious foodborne illness and they were willing to adopt food safety recommendations.

Author Conclusion:

The primary finding of this study with OT and SCT patients is that these are distinct patient populations with differing perceptions of the seriousness of foodborne illness and their willingness to adopt preventative food handling practices differs
In the future, educational strategies should be customized to fit the characteristics of each population.

Funding Source:

Government:

US Department of Agriculture grant no 99-35201-8126

Reviewer Comments:

The authors did note some limitations to this study

First, the sample size was small, with only five to 15 participants per focus group
Second, the application to the larger transplant population may be limited because the patients at the comprehensive cancer center (where these studies were conducted) may have been prescribed a low-microbial diet during treatment and into recovery.

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)	N/A
	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)	N/A

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?		No
	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?	No
	2.2.	Were criteria applied equally to all study groups?	Yes
	2.3.	Were health, demographics, and other characteristics of subjects described?	No
	2.4.	Were the subjects/patients a representative sample of the relevant population?	No
3.	Were study groups comparable?		Yes
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	Yes
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	Yes
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	Yes
	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?		Yes
	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%.)	Yes
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	Yes
	4.4.	Were reasons for withdrawals similar across groups?	Yes
	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?		N/A
	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.)	N/A
	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?		Yes
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	N/A
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	Yes
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	N/A
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	N/A
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.6.	Were extra or unplanned treatments described?	N/A
	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?	Yes
	7.7.	Were the measurements conducted consistently across groups?	Yes
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		???
	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?	No
	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)?	No
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	No
	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?	No
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