EAL

MHFS: Food Safety (2012-2013)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

The aim of this study was to gather information about local consumer knowledge and attitudes towards safe food-handling, in order to design a national health promotion campaign aimed at the person preparing food in the home
Only once existing attitudes and practices regarding food safety are recognized will it be possible to plan effective strategies to encourage healthy behaviors and discourage unsuitable ones.

Inclusion Criteria:

The notified Salmonella cases through a whole year (30 cases) were included
Two controls per case were selected at random from the local population electoral register database
All controls were matched according to the same year of birth and locality.

Exclusion Criteria:

Not described.

Description of Study Protocol:

Recruitment

Three focus groups with participants randomly selected from the population
The sampling frame was the computerized national electoral register database maintained by the Government of Malta, which lists everyone over the age of 18 currently residing in the Maltese islands
Participants were invited to participate by means of a phone call from the investigator. The second part of the study was a case control study.
The sampling frame was the database of case reports maintained by the national Disease Surveillance Unit of the Public Health Department.

Design

Case-control study.

Statistical Analysis

Frequency distributions were made to describe the data, while inferential analysis was made using chi-square tests
Odds ratios were used to estimate the strength of the association between a case and knowledge, awareness and attitudes of safe food-handling, as differing from controls
The computer program Epi Info 6 was used for analysis of this study.

Data Collection Summary:

Timing of Measurements

The participants in the focus groups were presented with a series of questions with the aim of generating discussion and interaction with the group
The results from the focus group studies and questions used in various international studies provided materials for the development of a questionnaire
An appointment was made for a visit to the home of the cases and controls and the investigator administered the questionnaire
The cases were contacted about a month after having been investigated by the Disease Surveillance Unit, while the controls were interviewed within the same week as their matched case to decrease bias from external factors such as food safety information and campaigns or media reports.

Dependent Variables

Consumer knowledge and attitudes towards safe food-handling

The questions were based on ones that are generally raised by the general public and those used in a focus group study performed in the US in 1996
The questions included:
- How would you know if your food is safe?
- What can harm you in food?
- How do you know if food has been cooled/reheated well?
- Who taught you how to cook?
- What is the impact of media reports of food borne illness outbreaks
- What is the best way for you to receive information regarding food safety measures?
The responses were hand-written in the notes taken by the investigator and the content analyzed by grouping key words or phrases into main themes.

Independent Variables

Cases vs. controls.

Description of Actual Data Sample:

Initial N: 84 total; 24 participants from focus groups (eight in each group) plus 30 cases and 30 controls. The focus groups represented parents of young children, young adults and senior citizens.
Attrition (final N): 84 total; 24 participants from focus groups (eight in each group) plus 30 cases and 30 controls
Age: Not described
Ethnicity: Not reported
Other relevant demographics: Not reported
Anthropometrics: Not reported
Location: Malta.

Summary of Results:

Key Findings

Individuals who had been exposed to salmonellosis, or who had a dependent who had been exposed, had developed a higher level of food safety knowledge and awareness
Variations between knowledge and self-reported practices make it apparent that persons have to be convinced that food safety measures are effective before they take action to change their behavior
There were repeated misconceptions about thawing food especially among the senior citizens' group
The Young Adults' Group did not tend to check labels before purchasing food, while the seniors reported that they did so mainly when they got home
Overall consumer food safety knowledge in all groups was generally good. There were a number of misconceptions, especially relating to the temperature for storage and cooking and use of thermometers.
Both cases and controls had similar levels of education: 41% of participants had completed 11 years of education and 18% completed further studies
A similar number of cases (30%) and controls (28.8%) stated that only occasionally did they not use the same utensils for raw and cooked foods
A large proportion of cases (70%) and controls (68%) reported that they always covered or wrapped food before storing it in the refrigerator, yet 50% of cases and 59% of controls occasionally stored raw food on a shelf above cooked food in the refrigerator
This study showed significant differences between cases and controls: A higher percentage of controls (48%) than cases (30%) stated they would always buy their eggs from street hawkers or breeders in private homes. This difference was statistically significant (P=0.021).
Fewer cases (27%) than controls (76%) (p=0.00002) stated that they believed temperature ranges were important to prevent food from being contaminated.

Author Conclusion:

In conclusion, consumer education strategies need to emphasize the burden of illness, making safe food-handling meaningful to consumers
Continuous reinforcement of the messages may be effective in empowering the consumer to foster behavior change.

Funding Source:

University/Hospital:

Department of Public Health, University of Malta Medical School

Reviewer Comments:

It is possible that the study did not identify associations on food safety issues because very few of the participants had higher levels of education
Also, the Maltese society is very integrated and marriages between different social strata are frequent, which would tend to reduce the effect of bias caused by family-inherited knowledge on food safety.

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?		Yes
	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?	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?	Yes
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?	Yes
	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.)	Yes
	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?	Yes
	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?		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?	N/A
	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