I: t... a. .. r a .v/r» in... ,4. l}. 4!.) . Pi...) :. no 4 » fv, '; 3, . . w y. . .1. ....rltlc 91...... .. 1...: .i. I. 5.; . 1...: .. .4. (1.9.2.;12 .23.. 4.! . . 1. 7...: x . {yr} .330: 1r lip-tut». loin. tirib. . .11 Ill]. 23.3-11.7 .- ..‘....-...-. ., .. .,....-. nu. . . «I'll; fcvv. t.» gilt: brYLv. 166813 lllllllllll')lllHlllHlUllllllllllllllllllllllllllllllll 31293 00897 7625 This is to certify that the thesis entitled Michigan Health Information Porviders: Knowledge of Safe Food Handling presented by Kuo—Tung Li has been accepted towards fulfillment of the requirements. for Master Institution Administration Jegree in a kw‘fii (if , jml .1 C")- Major professor Date ill/~13/fil 0-7639 M5 U is an Affirmative Action/Equal Opportunity Institution LIBRARY Michigan State Unlversity PLACE IN RETURN BOX to remove this checkout from your record. TO AVOID FINES return on or before date due. DATE DUE DATE DUE DATE DUE ll . __l l II _J A , MSU I. An Affirmative Action/Equal Opportunity lnditutlon czbircmpma-pJ .. __ NICHIGRN HEALTH INFORMATION PROVIDERS: KNOWLEDGE OF SAFE FOOD HANDLING BY nun-rung Li A THESIS Bunnitted to nichigen stete University in pertinl fulfillment of the requirenente tor the degree of EASTER 0’ SCIENCE Depertnent of Food Science end Human nutrition 1992 ABSTRACT NICHIGAN HEALTH INFORMATION PROVIDERS: RNO'LEDGE OP SAFE FOOD HANDLING 3? Rue-rung L1 This study is one component of a Michigan statewide assessment of the food handling knowledge of: third-grade children and their household members, third-grade teachers, school foodservice personnel, and health information providers (HIPs). This thesis provides the results of the knowledge assessment of HIPs--foodservice sanitarians, health educators, nurses, nutritionists, physicians affiliated with local health departments and family practice physicians. Questionnaires with eight questions about food handling and 18 demographic questions were mailed to 1,541 HIPs (local health department personnel, N=891; family practice physicians, N=650) during October 1991. The response rate was 48.0% (local health departments = 68.5%, family practice physicians = 19.8%). The results support the need to provide current, accurate, and continuing education about safe food handling for all groups of HIPs. Knowledge constructs to emphasize include time- temperature relationships of food handling and the identification of potentially hazardous foods. ACKNO'LEDGEHENT The author wishes to express his thanks to his advisor, Dr. Carol Sawyer, for her valuable advice and sincere assistance while completing his master's studies. This experience has helped the author be well-prepared for his future job in Taiwan which is in the area of food safety. This genuine appreciation is also extended to the members of the Mary Lewis Project -- Dr. Sandra Andrews and Dr. June Youatt -- for all of their help and.guidance over the last two years. Special thanks goes to Dr. Ann Murphy for her sincere efforts to interpret data which enhanced the quality of this thesis as well as the author's understanding of the research process. The author would also like to thank Dr. William Helferich for his thorough review of this thesis. The author would thank.Ange1a Fraser for her help during his M.S. program. Last but not least, the author wishes to express deepest appreciation to his parents, Mr. C.F. Li and Mrs. L.C. Li, his girlfriend, C.L. Yeh for their love and support. iii TABLE OF CONTENTS Begs nrsr or rannrs ........................................ vii LIST 0’ rIGURBB O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 0 ix LIST or ”mecna O O O O O O O O O O O O O O O O O O O O I O O O O O O C O O O O O O O O 1 . o Imonucrlox O O O O O O O O O O O O O O O O O O O O O O O O O I O O O O O O O O O O O O 2.0L1Tmmm1" O...0..OOOOOOOOOOOOOOOOOOOOOOO... h a» r4 x 2.1 FOOd safety OOOOOOOOOOOOOOOO0.00.0.0...0.. .5 2.1.1 Foodborne Disease Outbreak Statistics .... 2.1.2 Foods Implicated in Outbreaks of Foodborne Disease ................................ 2.1.3 Factors Contributing to Foodborne Disease ................................ .1.4 Previous Research on Food Safety ......... @QG Health information Providers ............. 13 1 Local Health Departments ................. 14 2 Family Practice Physicians ............... 16 .3 References 0.0000000000000000000000...O... 20 3.0 HNO'LEDGE OF SAFE FOOD HANDLING OF HEALTH INFORHATION PROVIDERSMATWIICHIGANMLOCALHHEALTHIDEPARTMENTS ...... 27 3 O 1 AbatraCt O O O O .0 O O O O O O O O O O O O O O O O O O O O O O O O O O O O 27 3 O 2 IntrOduCtion O O O O O O O O O O O O O O O O O O O O I O O O O O O O O 28 3 O 3 Heads 0 O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 3 1 3.3.1 Description of the sampling frame ........ 31 3.3.2 Development of the questionnaire ......... 31 3.3.2.1 Demographics ............................. 31 3.3.2.2 Knowledge of safe food handling .......... 32 3.3.3 Obtaining the samples .................... 33 3.3.4 Mailing .................................. 34 iv 3.3.5 Statistical analyses ..................... 3.4 Results and Discussion ................... 3.4.1 Response rate ............................ 3.4.2 Demographics ............................. 3.4.3 Knowledge of safe food handling .......... 3.4.3.1 Food temperature and storage ............. 3.4.3.2 Personal hygiene ......................... 3.4.3.3 Cross-contamination ...................... 3.4.3.4 Identification of potentially hazardous foods .................................. 3.4.4 Statistical analyses of knowledge scores by demographics ........................ 3.5 Conclusions and Recommendations .......... 306 References OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 4.0 XNO'LEDGE OF SAFE FOOD HANDLING OF MICHIGAN rHILY PMCTICB PHYSICIANS OOOOOOOOOOOOOOOOOOOOOOOO 4 O 1 Abstract O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 4 O 2 IntrOduction O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 4 O 3 HethOdS O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 4.3.1 Description of sampling frame ............ 4.3.2 Development of the questionnaire ......... 4.3.3.1 Demographics ............................. 4.3.3.2 Knowledge of safe food handling .......... 4.3.3 Obtaining the samples .................... 4.3.4 Mailing .................................. 4.3.5 Statistical analyses ..................... 4.4 Results and Discussion ................... 4.4.1 Response rate ............................ 4.4.2 Demographics ............................. 4.4.2.1 Personal demographics .................... 4.4.2.2 Professional demographics ................ 4.4.3 Knowledge of safe food handling .......... 4.4.3.1 Food temperature and storage ............. 4.4.3.2 Personal hygiene ......................... 4.4.3.3 Cross-contamination ...................... 4.4.3.4 Identification of potentially hazardous foods .................................. 4.4.4 Statistical analyses of knowledge scores by demographics ........................ 4.5 Conclusions and Recommendations .......... V 4 O 6 References O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O s. o concnuslons O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 6.0 RECOMMENDATIONS FOR FUTURE RESEARCH ............... 7.0”Pm1cns OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO vi 92 96 98 99 LIST OF TABLES vii RENEE: RARE 2.1 Factors contributing to the occurrence of 345 foodborne disease outbreaks resulting from foods prepared in the home from 1973-1982 ......... 7 3.1 Response rates by a group of Michigan health information providers for all questionnaires mailed OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 37 3.2 Demographic characteristics of participating Michigan health information providers ............. 40 3.3 Types of interaction on safe food handling with children and/or their families noted by Michigan health information providers ...................... 44 3.4 Sources of safe food handling information identified by Michigan health information providers .......... 45 3.5 Construct of knowledge questions on safe food handling and percent of correct responses by five groups of health information providers ............ 48 3.6 Analysis of the variance of demographic factors on a total score of eight knowledge questions for Michigan health information providers ............. 53 3.7 Safe food handling objectives for further training of foodservice sanitarians ........................ 59 3.8 Safe food handling objectives for further training Of health educators OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 60 3.9 Safe food handling objectives for further training Of public health nurses OOOOOOOOOOOOOOOOOOOOOOOOOOO 61 3.10 Safe food handling objectives for further training of public health nutritionists ................... 62 :3.11 Safe food handling objectives for further training of public health physicians ...................... 63 Personal demographic characteristics of participating family practice physicians .......... Professional demographic characteristics of participating family practice physicians .......... Construct of knowledge questions on safe food handling and percent of correct responses by family practice physicians ........................ The effect of the demographic variables of family practice physicians on their knowledge of safe toad handling 0.0.0....O0.00000000000000.00.0000... Safe food handling objectives for further training of family practice physicians ...................... viii 78 80 83 87 91 LIST OF IIGUREB HBEDEI 3.1 Percent of total respondents (n=611) represented by each of five groups of Michigan health information prOViders CCOOOOOCOOOOOOOOOOOOOOOO0..C. Plot of percent of total correct responses to eight knowledge questions by Michigan health information providers, by gender and training ..... Plot of percent of total correct responses to eight knowledge questions by Michigan health information providers, by age and years in specialty area ..................................... ix 38 56 57 LIST OF APPENDICES Number , 2392 1. A project statement requesting Michigan local health departments to participate in the study .00...0......OOOOOOOOOOOOOOOOOOOOOOOO 99 2. A reply card for Michigan local health department use 0.0.0000000000000000000000000...... 101 3. A cover letter for each participating local health department OOOOOOOOOOOOOOOO0000...... 102 4. A return sheet for each participating local health department .......................... 103 5. Response frequencies of health information providers (n=611) affiliated with local health departments OOOOOOOOOOOOOOOOOOOOOIOOOOOOOOOOOOOOOO 104 6. Response frequencies of foodservice sanitarians (n=214) affiliated with local health departments . 112 7. Response frequencies of health educators (n-52) affiliated with local health departments ......... 117 8. Response frequencies of public health nurses (n=260) affiliated with local health departments . 121 9. Response frequencies of public health nutritionists (n=61) affiliated with local health departments .. 126 10. Response frequencies of public health physicians (n=24) affiliated with local health departments .. 131 11. A cover letter requesting Michigan family practice physicians to participate in the study ........... 136 12. Response frequencies of family practice thSiCians (“8129) OOOOOOOOOOOOOOOOOOOOIO000...... 137 to1 De: han COn lis. 1 . 0 INTRODUCTION Food safety has become a major concern of consumers and governmental regulatory agencies in U.S.. Among the threats posed by potentially unsafe foods, microbiological hazards have been identified as the most common and the most serious (Wolf, 1992; Swintek, 1991; Titus and Talbot, 1991). Foodborne disease, most often caused by bacterial pathogens, is a significant health problem in the United States. The Centers for Disease Control (CDC) stated that foodborne disease is one of the most common and significant causes of illness and death in the United States (Banwart, 1989). The CDC estimated that up to 81 million cases of foodborne disease with 9,000 related deaths occur yearly (USDA, 1989a; Bennett et a1., 1987; Amler and Dull, 1987; Archer and Kvenberg, 1985). Unlike many types of disease, foodborne disease is almost totally preventable when food is handled safely. Thirty percent of all reported foodborne disease resulted from unsafe handling of food in the home (Hecht, 1991). A 1991 national consumer survey showed that the home was ranked third in a listing of sites (after food manufacturing facilities and restaurants) where food safety problems are most likely to 2 occur (Gravani, 1992). Many researchers have suggested that foodborne disease could be prevented if food is handled safely, especially during the final stages of preparation before service (Lawson et a1., 1990; Mossel, 1989; Weinstein, 1990; USDA, 1990a; Jacob, 1989; USDA.FSIS.July, 1989a; Holmes, 1989; Wolf and Lechowich, 1989; Hunter, 1987). {According to CDC data, the most frequently reported food preparation practices contributing to foodborne disease were improper storage or improper holding temperatures; poor personal hygiene followed (Bean and Griffin, 1990). Numerous studies have indicated that consumers in the 0.8. are not always knowledgeable about safe food handling, especially in the areas of cold-storage temperatures, storage of leftovers, and methods of thawing foods (Gravani, 1992; USDA/FDA, 1991). Consumer awareness can only be accomplished through education that positively influences long-term behavioral changes. Health information providers (HIPs), such as those who work for local health departments (foodservice sanitarians, health educators, public health nurses, public health nutritionists and public health physicians) and family practice physicians, have been recognized as a potentially influential adult population for children and their families in the area of safe food handling (Gravani, 1992; Dismuke and Miller, 1983) . Previous assessments of the safe food handling knowledge of HIPs were not found in the literature. Thus, the purpose of this study was to assess the safe food handling 3 knowledge of HIPs and to determine their training needs in this area. A! 2.0 LITERATURE REVIEW 2.1 Food Safety The food supply in the United States is one of the most abundant and nutritious on earth; it may also be one of the safest. Because of more stringent government regulation and greater knowledge about proper sanitation, foods are safer today than in the "good old days." However, a great many illnesses and deaths occur in the united States each year because of foodborne disease. 2.1.1 Foodborne Disease Outbreak Statistics The incidence of foodborne disease is on the rise in the U.S. (USDA, 1990b). Furthermore, most cases result from the mishandling of food in foodservice establishments or in the home (Raithel, 1988). Of the 7,219 foodborne disease outbreaks occurring between 1973 and 1987 (when the site was reported), 79% of the outbreaks were attributed to foods prepared in commercial or institutional establishments, while 21% were attributed to foods prepared in the home (Bean and Griffin, 1990). Although the exact number of people in the U.S. who contract foodborne diseases is unknown, between 6.5 and 81 in an 5 million outbreaks are estimated to occur each year in U.S. (Bean and Griffin, 1990) . Other researchers estimate the number of cases to be between 68.7 and 275 million (Archer and Kvenberg, 1985) . The number of deaths by foodborne disease is reported annually; recent estimates for the U.S. range from 523 to 7,041 per year. These numbers indicate that even with variations in reporting procedures, foodborne disease is widespread and can have many serious health consequences, including death (Todd, 1989). A foodborne disease outbreak has been defined as an incident in which two or more persons experience a similar illness and food is implicated (Bean et a1., 1990) . Foodborne disease outbreaks can be economically devastating. A study of 17 foodborne disease outbreaks in the United States and Canada found that each outbreak cost an average of $200,000 (Archer and Kvenberg, 1985) . The costs included medical care, lost wages, public health investigations, lost business, and legal fees. Occasionally, entire industries have been crippled (USDA, 1989a) . Foodborne disease has been estimated to cost the U.S. between $3.5-17 billion per year (USDA, 1989a). Nearly everyone has an economic interest in preventing foodborne disease. The CDC summary report of foodborne disease from 1973 to 1987 , reported that reported foodborne disease outbreaks increased steadily during the first 10 years (1973 to 1982) and decreased over the past five years (1983 to 1987) . tr in it be. Um 6 Furthermore, there is sufficient evidence to indicate that the decrease in the number of reported outbreaks during the years 1982-1987 stems from reporting changes (Bean and Griffin, 1990). The decrease in reported outbreaks since 1982 parallels the increased burdens imposed on local health departments by the Acquired Immune Deficiency Syndrome (AIDS) epidemic. The many cases of AIDS might have caused a diversion of reporting resources away from foodborne disease surveillance. 2.1.2 Foods Implicated in Outbreaks of Foodborne Disease Foods frequently implicated in outbreaks are termed "potentially hazardous" . foods. These foods are hazards because they usually provide a sufficient quantity and variety of nutrients, have a water activity above 0.85, have a pH greater than 4.6, and possess the proper oxygen requirements that are required to support the rapid growth of infectious or toxigenic microorganisms (FDA, 1986) . When such foods are stored at unsafe temperatures (45-140°F) , disease-causing organisms can grow to dangerous levels (Banwart, 1989) . In the reported outbreaks from 1973 to 1987, a specific food was implicated in 50% of the outbreaks. However, it is important to understand that the food itself does not cause foodborne disease, but rather that it becomes contaminated with bacteria by being maintained at unsafe temperatures, by mishandling, or by improper (“I D: 7 preparation or storage. Multiple factors are usually involved in foodborne disease outbreaks. 2.1.3 Factors Contributing to Foodborne Disease Bryan (1988) identified 12 factors that contributed to foodborne disease outbreaks in U.S. homes from 1973-1982. These factors are shown in Table 2.1. TABLE 2.1: Factors that contributed to the occurrence of 345 foodborne disease outbreaks that resulted from foods prepared in the home from 1973-1.982.1 FACTOR NUMBER PERCENT 1. Contaminated raw food or ingredient 145 42.0 2. Inadequate cooking/heating 108 31.3 3. Obtaining food from unsafe source 99 28.7 4. Improper cooling 77 22.3 5. Lapse of 12 or more hours between , 44 12.8 preparing and eating food 6. Colonized person handling implicated 34 9.9 foods 7. Improper fermentation 16 4.6 8. Inadequate reheating 12 9. Improper hot holding 11 10. Cross contamination 11 3.2 11. Improper use of leftovers 12. Improper cleaning of utensils 1 0.3 1. Bryan, 1988. The data in Table 2.1 suggested a need to inform the public about hazardous situations unique to home food preparation (Bryan, 1988) . Contaminated raw foods or DJ Co 8 ingredients were the leading factor which contributed to foodbornezdisease in the home; they caused 42% of the reported foodborne disease outbreaks from 1973-1982 (Bryan, Table 2.1) . This was primarily due to raw clam-, oyster- and milk-associated outbreaks. Factors in Table 2.1 can also be associated with specific disease causing bacteria. The most important factors contributing to outbreaks of salmonellosis were improper cooling methods, (such as leaving foods on the countertop at room temperature for >4 hours) and naturally contaminated raw foods that were improperly cooked (Bryan, 1988) . Factors contributing to staphylococcal intoxication were colonized persons handling foods that required no further cooking, a lapse of time between food preparation and consumption (>4 hours) , and improper cooling methods. Clostridium perfringens outbreaks were caused by improper cooling methods, a lapse of time between food preparation and consumption (>4 hours), and inadequate reheating temperatures (<165°F) . The factors contributing to botulism outbreaks included inadequate cooking temperatures (<165°F) , improper fermentation process, and improper temperature during holding (<140°F)(Bryan, 1988). 2.1.4 Previous Research on Food Safety Before public education and training programs are planned, food safety professionals must first learn what consumers know about safe food handling. Several state and 9 national surveys were conducted to learn about consumer food safety knowledge and home preparation practices. In 1973 the Gallup’Organization conducted.a survey investigating consumer knowledge about salmonella. The survey consisted of personal interviews with 816 randomly selected U.S. women 18 years of age or older. Major findings of the survey included the following high risk practices: 0 39% of respondents thought the USDA specifically inspected foods for salmonella. o 74% could not correctly identify salmonella. o 94% did not know that handwashing minimized the spread of harmful bacteria. In 1974 a comprehensive food safety survey was conducted by USDA. The objectives of survey were: 1). to access homemakers' food safety knowledge and practices, 2) to identify groups of people having the greatest need for food safety information, and 3) to identify the most effective ways to disseminate food safety information (Weimer and Jones, 1977). Major topics covered in the survey included home food handling, bacterial sources of food contamination, food safety information, and government food inspection programs. In March 1983, Oregon State University's Department of Foods and Nutrition researchers Woodburn and Van DeRiet (1985) 10 conducted personal interviews on food safety practices of 100 randomly selected adults from Portland and Yamhill County, Oregon. Their findings are below: 0 34% of respondents would not wash the knife, cutting board, and hands after handling raw chicken and before cutting vegetables for salad. 0 9% would not wash the work surface after cutting raw chicken on it and before removing cooked meat from bones. o 29% would chop giblets for a sandwich without washing the board that held the raw turkey. o 28% would only wipe or rinse the knife after cutting fresh chicken. 0 27% would thaw turkey at room temperature. a 24% would hold sliced roast beef at room temperature for over three hours; 13% would hold chicken salad and 10% would hold beef pot pie under the same conditions. 0 58% believed that the maximum time a turkey could safely remain at room temperature was over two hours. 0 50% would cool most foods to room temperature before refrigerating. o 22% would cool beef pot pie to room temperature before refrigerating. o 26% would hold turkey at room temperature for over six hours; 33% would hold ham and 22% would hold beef pot pie under the same conditions. 11 A national survey conducted by the USDA, Food Safety Inspection Service (USDA/FDA, 1991) consisted of 3,202 telephone interviews in the U.S. of which 2,797 responded. Respondents, who prepared the main meal, were asked about food handling knowledge. Major findings of this survey concluded that: o 71% of respondents used unsafe methods to cool a large pot of stew or soup. 0 48% of respondents used inadequate cleaning practices. 0 97% of respondents rated themselves "average" or "above average" with respect to food safety knowledge. 0 85% of respondents knew that food which looks and smells "okay" can still contain harmful bacteria. 0 84% of respondents knew that juices of raw meat and poultry are likely to contain bacteria. In March 1990, Michigan State University's Department of Communications in cooperation with Lawler Ballard Inc. conducted 600 statewide telephone interviews (Atkins, 1990). Major findings concerning home food preparation practices were as follows: 0 When asked to list their most important consideration in purchasing food, 57% of respondents said price, followed by 27% who said quality or value, and 12% who chose nutrition. 12 o 86% felt "very" or "somewhat” confident that the food in stores was safe. 0 When asked to list their primary food safety concern, 30% said freshness/spoilage, 27% pesticides/chemicals and 15% packaging. o 94% considered poor food handling to be a ”serious” or "somewhat serious" health hazard. The objectives of a national survey completed at Cornell University were to obtain current information on consumer food safety knowledge and home food preparation practices (Gravani, 1992). The study covered 2,005 U.S. households, of which 869 respondents were asked about their food handling knowledge. Major findings of this study are below: 0 59% of respondents did not avoid foods because they were concerned about foodborne illness. 0 24% did not understand that a food may contain pathogenic bacteria even if it does not smell, taste, or look bad. 0 17% would not wash hands after handling raw chicken and 14% would not do so after sneezing. o 54% would store leftover stew in deep containers, and another 14% in the pot in which it was cooked. o The source of food safety information ranked highest as 0F co he. 8&1 "it Phy 0f 1 (Ada iden1 l3 "reliable" or "very reliable" by respondents was newspapers, magazines, and health professionals (75% for eacn). 0 Television was considered "the most convenient" way to obtain food safety information (33%) , followed by newspapers (22.8%), and magazines (8.8%). Data gathered in these state and national surveys have and will continue to help universities, government agencies, and the food industry’ to design. appropriate and ‘useful strategies for educating the public about food safety in the home. 2.2 Health Information Providers Research has shown that U.S. consumers believe that health professionals provide reliable food safety information (Gravani, 1992) . Health professionals have many opportunities to provide information on food safety to consumers (Valente et a1., 1986). Many different groups of health professionals may influence consumer knowledge of food safety: one such group is health professionals affiliated with local health departments; the other is family practice physicians. In recent years, consumers have become increasingly aware of the role food safety plays in the maintenance of health (Adam and Sachs, 1991) . The major food safety concerns identified by consumers have been food additives and pesticide is Dr. 14 residues (Huang, 1992; Wolf and Lechowich, 1989; Albrecht, 1986). Microbiological hazards, identified by scientists as being of greater concern, received less attention by consumers (Beran, 1991; Wolf and Lechowich, 1989; Albrecht, 1986). The regulatory sector ranks microbiological hazards as the highest food safety risk issue (Beran, 1991; USDA, 1989b; Wolf and Lechowich, 1989; Albrecht, 1986). Industry representatives also share this view. One recent survey (Swintek, 1991) asked major food.processors to rank potential food hazards. The results of the survey showed that microbiological hazards topped the list, with 91% of respondents considering microbiological hazards to be of high- to-medium importance. Consumers' two perceptions about food safety--the degree of risk from food contamination and reliable sources of information-~may indirectly affect their food handling behavior. Thus, consumers need to be educated about microbiological hazards, especially those from improperly handled foods. 2.2.1 Local Health Departments The mission of all local health departments in Michigan is to "continually and diligently endeavor to prevent disease, prolong life, and promote the public health" (Michigan Public Health Code, 1987). Local health departments provide free be we HI Sp. 15 resources indirectly or directly to the public and.are thus an economically viable source of food safety information. One study reported that consumers didn't avail themselves of many of the services of local health departments (Gravani, 1992) . Over 40% of survey respondents never used such services. Increasing awareness about the availability of local health department services could be an important way to disseminate effective food safety information. Many HIPs affiliated with local health departments (health educators, public health nutritionists, public health nurses, and public health physicians) pay less attention to foodborne disease than they did in the past. They tend to target the prevention of AIDS and venereal diseases, pandemics (tobacco- and alcohol-related illnesses and deaths), poverty and its attendant health problems, and issues of priority (immunization ‘versus transplantation, rationing of care) because these are currently perceived as more critical public health issues (Houston, 1991). Information about HIPs' knowledge of safe food handling was not found in the literature. However, various groups of HIPs have been evaluated on other general competencies specific to their specialty (Hatfield, 1991; Gantt, 1987; Williams et a1., 1989; Weinstein, 1989). r. in 16 2.2.2 Family practice Physicians In recent years, Americans have become increasingly aware of the role food safety--microbiologica1 hazards, pesticide residuals, additives, etc.--plays in the maintenance of health (Adam and Sachs, 1991) . However, many Americans do not correctly perceive the high risk of foodborne disease from microbiological hazards which may result from unsafe food handling (Gravani, 1992; USDA/FDA, 1991). The public perceives physicians as a credible source of health information (Gravani, 1992; Kunkel, 1986; Dismuke and Miller, 1983) . Some researchers have reported that physicians' knowledge of food and nutrition might be inadequate and/or outdated (O'Keefe, 1991 ; Sobal et a1. , 1988; Winick, 1988; Sobal et a1., 1987; Krause, 1977). Research supports the possibility that nutrition education in medical school (or the lack of it) may be a variable influencing the physician's food and nutrition knowledge (Krause, 1977) . White et al. found that physicians obtained most of their nutrition education from residency programs and experience in practice. According to Murphy (1990) , physicians' opinions about nutrition can be influenced positively by a nutrition education intervention, such as a seminar series, during residency. Interestingly, physicians who attended continuing education programs on nutrition did not significantly differ in their knowledge about nutrition from those who did not 17 attend such programs. This may suggest that physicians are more likely to be influenced favorably when nutrition education occurs in a residency program before beginning office practice. ‘ Many studies have also shown that nutrition receives insufficient attention in medical school curricula (Swanson, 1991; Weinsier et a1., 1989). Two surveys reported that 61% (GPEP, 1984) and 67% (McLeod, 1989) of graduating medical students believed inadequate time was devoted to nutrition education. The nutrition education provided was sporadic and poorly' organized in many medical schools and residency programs (Walsh, Dappen and Gessert, 1987; Young, 1988). Family practice physicians are most often currently trained in their specialty in formal three-year residency programs. They are trained to evaluate total health needs, to provide personal medical care within one or more fields of medicine, to refer patients when necessary, and still maintain a continuity of care (AAFP, 1991a). Family practice physicians treat 85 to 90% of patient's health care needs within their practice area. Equally important, their training teaches them to practice ”preventive” medicine. In 1986 family practice physicians represented 11.9% of the total number of physicians (569,160) in the U.S. In terms of size, family practice was ranked second among all specialties. American Medical Association (AMA) data also showed that family practice physicians conduct more patient 18 visits per week than do other types of physicians. Family practice physicians devoted a mean of 57.9 hours per week to professional activities, of which a mean of 48.9 were devoted to direct patient care. Family practice physicians were sought after by managed care systems not only because they offer a broad range of services, but because they are perceived as cost-efficient users of resources. Large multihospital and multisystem organizations have a vested interest in utilizing resources efficiently, and family practice physicians might meet such interests by serving as ”case managers." In addition to the economic considerations, managed-care systems place high values on disease prevention and health promotion. Family practice physicians, because of their potential influence on the lifestyles of their patients, are involved in health and societal issues that affect the well-being of their patients. Thus, concerns about preventive health care measures have the potential to claim a larger role in the practice of family practice physicians. The Michigan Academy of Family Physicians (MAFP) is a state association of doctors of medicine and osteopathy who are engaged in family practice (MAFP, 1992). The basic goals of the MAFP are: 1) to constantly maintain and improve high standards of family practice; 2) to promote the science and art of medicine and surgery, improve the public health, and to preserve the patients' right to free choice of physicians; and 19 3) to acknowledge and assume responsible public advocacy in all health-related matters. As in the American Academy of Family Physicians there are seven types of MAFP memberships: student, resident, active, affiliated, sustaining, inactive, and life members (AAFP, 1988) . Active members make up the bulk of Academy membership. To be eligible for active membership, a candidate must be a graduate of a school of medicine or osteopathy, hold a certificate of qualification recognized by the AMA, or hold a Doctor of Osteopathy degree and have completed a three-year family practice residency. The primary obligation of active membership is fulfillment of 150 hours of study acceptable to the Commission on Continuing Medical Education (CME) during the preceding three years. This guarantee of competence is met through various CME programs. 2.3 References Adams, C.E. and Sachs. 1991. Government's Role in Communicating Food Safety Information To the Public. Food Tech. 45(5):254-255. Albrecht, J.J. 1986. Business and technology issues in U.S. food science and technology. Food.Tech. 40(12):122- 127. AAFP (American Academy of Family Physicians). 1991a. Family practice is a medical specialty. Kansas City, Mo. AAFP (American Academy of Family Physicians). 1991b. Facts about the specialty of family practice. Kansas City, Mo. AAFP (American Academy of Family Physicians). 1988. AAFP membership classification chart. Kansas City, Mo. AAFP (American Academy of Family Physicians). 1987. Facts about family physicians. Kansas City, Mo., Burd & Fletcher Inc. Amler, R.W. and Dull H.B. 1987. Closing the gap: The burden of unnecessary illness. Oxford University Press, New York, NY. Archer, D. L. and Kvenberg, J. E. 1985. Incidence and cost of foodborne diarrheal disease in the United States. J. Food Protect. 48(10): 887-984. Auld, E. 1990. Risk communication and food safety. Dairy, Food and Envir. Sanit. 10(6):352-355. Banwart, G.J. 1989. Basic food.microbiology. 2nd edition. Van Nostrand Reinhold publication, New York, NY. Bean, N.H. and Griffin, P.M. 1990. Foodborne disease outbreaks in the United States, 1973-1987: pathogens, vehicles, and trends. J. Food Protect. 53(9):804-817. Bean, N.H., Griffin, P.M., Goulding, J.S. and Ivey, C.B. 1990. Foodborne disease outbreaks, 5-year summary, 1983-1987. MMWR 39(ss-1):15-57. Bennett, J.V, Holmberg, S.D., Roger, M.F., and Solomon, s.L. 1987. Infectious and Parasitic Diseases. In "Closing the Gap: The burden of unnecessary illness," ed. R.W. Amler and H.B. Dull, Oxford University Press, New York, NY. 20 Fc 21 Beran, G.M. 1991. Food safety -- an overview of problems. Dairy, Food and Envir. Sanit. 11(4):189-194. Bryan, F. 1988. Risks of practices, procedures and processes that lead to outbreaks of foodborne diseases. J. Food Protect. 51(8):663-673. Carter, A.O., Vorczyk, A.A., Carlson, J.A.K., Harvey, B., Hockin, J., Karmali, M., Kirshman, C., Korn, D., and Loir, H. 1987. Severe outbreak of Escherichia coli 0157:H7 - associated hemorrhagic colitis in a nursing home. New Eng. J. Med. 317(24):1496-1500. Council on Long Range Planning and Development in Cooperation with the American Academy of Family Physicians. 1988. The future of family practice: Implications of the changing environment of medicine. JAMA 260(9):1272-1279. Dillman, D.A. 1978. Mailing and telephone surveys: the total design methods. John Wiley & Sons, New York, NY. Dismuke, S.E., and Miller, S.T. 1983. Why not share the secrets of good health? The physician's role in health promotion. JAMA 249(23):3181-3183. Donoghue, J. 1991. Health education and the national curriculum. Health Education Journal 50(1):16-17. Eilers, J.R. 1990. U.S. food poisoning cases greatly under -reported; long recognized pathogens remain significant. Food Processing 51(6):110-116. Feachem, R.G. 1984. Interventions for the control of diarrheal diseases among young children: Promotion of personal and domestic hygiene. Bull. World Health Org. 62(3):467-476. Flowers, R. 1988. Salmonella in bacteria associated with foodborne diseases. Food Tech. 42(4):182-184. Food and Drug Administration. Retail Program Information Manual, Part 6, Center for Food Safety and Applied Nutrition, Retail Food Protection Branch, HFF-342, 1986. Food Marketing Institute. 1991. Trends: consumer attitudes and the supermarkets, 55-61. Foster, G.M. and Kaferstein, F.K. 1985. Food safety and the behavioural science. Soc. Sci. Med. 21(11):1273-1277. 22 Gantt, J.M. and Terrell, E.L. 1987. External evaluation of CDC Homestudy course 3010-G "Community Hygiene." Journal of Envir. Health 49(6):348-353. Gravani, R., Williamson, D., and Blumenthal, D.. 1992. What do consumers know about food safety? FSIS Food Safety Review 2(1):12-14. Harrington, R.E. 1992. The role of employees in the spread of foodborne disease - food industry views of the problem and coping strategies. Dairy, Food and Envir. Sanit. 12(2):62-63. Hatfield, T.H. 1991. The failure of sanitarians. J. of Envir. Health 53(5):23-24. Hecht, A. 1991. The unknown dinner guest: preventing foodborne illness. FDA Consumer 25(1):18-25. Holmes, 8. 1989. The hazards of healthy eating. Nursing Times 85(26):49-51. Houston, T.P. 1991. The roots of public health. J. Family Practice 32(3):257-258. Huang, C.L. 1992. Consumer perception of food safety. Dairy, Food and Envir. Sanit. 12(8):495-498. Hunter, B.T. 1987. Foodborne illness: a growing problem. Consumer Research magazine 70(2):11-14.‘ International Association of Milk, Food and Environmental Sanitarians. 1987. Procedures to investigate foodborne illness. 4th Ed. Int. Assoc. Milk, Food Environ. Sanitarians, Ames, Iowa. Jacob, M. 1989. Safe food handling: a training guide for managers of food service establishments. WHO publication. Jolliffe, F.R. 1986. Survey design and analysis. John Wiley & Sons, New York, NY. Koury, S.D. 1989. Food Sanitation and safety study course, 2nd edition. Iowa State University Press, Ames, Iowa. Krause, T.O., and Fox, H.M. 1977. Nutritional knowledge and attitude of physicians. J. Am. Diet. Assoc. 70(6):607- 609. 23 Kunkel, H.B., Cody; M.M., Davis, R.J., and Wheeler, F.C. 1986. Nutrition information sources used by South Carolina adults. J. Am. Diet. Assoc. 86(3):371-372. Lawson, R., Sosin, E. and Grossman, F.G. 1990. Good health: food poisoning alert! Redbook 176(1):46-57. Martin, E.A. 1980. Historical foundations for nutrition education research, in nutrition education research: directions for the future. National Dairy Council Conference, Rosemont, Il. McLeod, C. 1989. Dal grads identify practice areas where they were poorly prepared. Med Post 19:35. Michigan. 1987. Michigan public health code: Act 368 of 1978, as amended. Department of Management and Budget, General Service Section, Lansing, MI. MAFP (Michigan Academy of Family Physicians). 1992. Family medicine: The way it was is not the way it is. Okemos, MI. Moore, D.S. and McCabe, G.P. 1989. Introduction to the practice of statistics. W.H. Freeman and Company, Oxford, New York. Mossel, D. 1989. Food safety and the need for public reassurance. Food Science and Technology Today 3(1):1,2-10. , Murphy, P.S. 1990. Family physicians' opinions on nutrition after nutrition education. J. Am. Diet. Assoc. 90(11):1584-1586. O'Keefe, C., Hahn, D.F., and Betts, N.H. 1991. Physicians' perceptive on cholesterol and heart disease. J. Am. Diet. Assoc. 91(2):189-192. Paulson, D.S. 1992. Education of three handwashing modalities commonly in the food processing industry. Dairy, Food and Envir. Sanit. 12(10):615-618. Physicians for the twenty-first century. 1984. The GPEP Report: Report of the Project Panel on the General Professional Education of the Physician and College Preparation for Medicine. J Med. Educ. 59(11): part 2:15- 27. Raithel, K. 1988. Concerns, challenges of keeping nation's food supply safe in the zlst century being studied now. JAMA 260(7):15-16. 24 Reynolds, B. and Ried, L.D. 1985. Factors associated with public health nurses' perception of skill in chemical dependency assessment and referral. Journal of Drug Education 15(1):23-32. Roback G, Mead L, Randolph, L. 1987. Physician Characteristics and Distribution in the U.S.. Chicago, American Medical Association. Sandoval, W.M. and Mueller, H.D. 1989. Nutrition education at the work site: a team approach. J. Am. Diet. Assoc. 89(4):543-544. Snyder, O.P. and Poland, D.M.. 1990. America's "safe" food. Dairy, Food and Envir. Sanit. 10(12): 719-724. Sobal, J., Muncie, Jr; H.L.,‘Valente, C.M., DeForge, B.R., and Levine, D. 1987. Physicians' beliefs about vitamin supplements and a balanced diet. Journal of Nutrition Education 19(4):181-185. Sobal, J., White-O'Connor, B., and Muncie, H.L. Jr. 1988. The importance of nutrition topics among family medicine residents and faculty. Journal of Nutrition Education 20(1):2o-22. Swanson, A.G. 1991. Nutrition sciences in medical-student education. Am. J. Clin. Nutr. 53(3):587-588. Swintek, R.J. 1991. New products are king. Food Proc. 52(8):38-40. Titus, E.O. and Talbot, J.M. 1991. Emerging issues in food Life Science safety and quality for the next decade. Res. Office, Fed. of Am. Socs. for Exp. Biology, Washington, D.C. Todd, E.C.D. 1989. Preliminary estimates to the cost of foodborne disease in the United States. J. Food Protect. 52(8):595-601. US Department of Agriculture, Food Safety and Inspection Service. 1990a. Preventing foodborne illness: A guide to safe food handling. US Department of Agriculture, Food Safety and Inspection Service. 1990b. FSIS Facts, Bacteria that cause foodborne illness. US Department of Agriculture, Food Safety and Inspection Service. 1989a. FSIS Facts, Preventable foodborne illness, FSIS-34 May, 1989, 1-10. W1 Wi 25 US Department of Agriculture, Food Safety and Inspection Service. 1989b. A margin of safety: The HACCP approach to food safety education. US Department of Agriculture and the Federal Drug Administration. 1991. Results of the Food and Drug Administration's 1988 Health and Diet Survey, Food Handling Practice and Food Safety Knowledge of Consumers, May 1991, 24 pgs and appendices. Valente, C., Sobal, J., Muncie, H.L. Jr., Levine, D., and Antlitz, A. 1986. Health promotion: Physicians' belief, attitudes and practice. American Journal of Preventive Medicine 2(2):82-88. Walsh, J.M., Dappen, A., and Gessert, C. 1987. Factors affecting nutrition training in four family practice residencies. J. Am. Diet. Assoc. 87(11):1558-1560. Weimer, J. and Jones, J. 1977. Food safety: attitudes and practice. USDA Report No. 360. 155 pgs. Weinsier, R.L., Boker, J.R., Brooks, C.M., et a1. 1989. Priorities for nutrition content in a medical school curriculum: a national consensus of medical educators. Am. J. Clin. Nutr. 50(4):?07-712. Weinstein, B. 1990. Are you food safety savvy? Environmental Nutrition 13(8):1,6-7. Weinstein, E. 1989. Health educators: where are you? Health Education 19(6):21-22. White, P.L., Johnson, O.C., and Kibler, M.J. 1961. Council on Foods and Nutrition, American Medical Association: Its relation to physicians. Postgrad. Med. 30(5):502-507. Whitehead, F.E. 1970. Nutrition education research project: report of phase I. Office of Nutrition, Technical Assistance Bureau, Agency for International Development, Washington, D.C. Williams, A.R., Davis, R.G., Hale, 0.0., and Collins, T.R. 1989. Patterns of concern: Needs assessment and continuing education needs among public health physicians. The Journal of Continuing Education in the Health Professions 9(3):131-139. Winick, M. 1988. The nutritionally illiterate physician. Journal of Nutrition Education 20(1):s12-sl3. 26 Wolf, I.D. 1992. Critical issue in food safety, 1930-2000. Food Tech. 46(1):64-70. Wolf, I.D. and Lechowich, R.V. 1989. Current issues in microbiological food safety. Cereal Foods World. 34(6):468-472. Woodburn, M. and Van DeRiet, S. 1985. Safe food; Care and labeling for perishable foods. Home Economics Journal 14(1):210. Young, E.A. 1988. Nutrition in medical education. Nutr. News 51(3):9-11. 3.0 Knowledge of Safe Food Handling of Health Information Providers at Michigan Local Health Departments (I tr 9e am Sp. Sal re] Dot 3.1 Abstract This study was one component of a Michigan statewide assessment of the food handling knowledge of: third-grade children and their household members, third-grade teachers, school foodservicejpersonnel and.health information providers (HIPs) including sanitarians, health educators, nurses, nutritionists and physicians affiliated with local health departments. Fifty percent of Michigan local health departments participated in the study (n=24, N=48) . A questionnaire was mailed to 891 HIPs. The response rate was 68.5%. Almost half (48.4%) indicated they had opportunities to provide people with information about food handling, but 66% had not received formal training in food handling during 1991. Of the five HIP groups surveyed, sanitarians had the highest mean knowledge scores (mean score-89.4%); nurses had the lowest (mean score-66.8%). Significant differences (pg .01) in knowledge were found for the average effect of training and gender as well as the interaction of training and gender. No significant differences in knowledge were found among respondents across educational level, age, or years in specialty area- Results indicated additional education about safe food handling should address: time-temperature relationships of food handling and the identification of potentially hazardous foods. 27 C1 p: Si 1‘: it St 3.2 Introduction Foodborne disease has been a significant health problem in the United States during the 19803 and continues to be a serious problem into the 19903. Approximately 6.5 million cases of foodborne diseases are estimated to occur in the United States each year.1 Unlike many types of disease, foodborne disease is almost completely preventable by using safe food.handling practices. Thirty percent (30%) of all reported foodborne disease resulted from unsafe handling of food in the home.2 A 1991 national survey showed that consumers ranked the home third (after food manufacturing facilities and restaurants) among 3 Some sites where food safety hazards were likely to occur. researchers have suggested that foodborne disease can be prevented if food is handled safely, especially during the final stages of preparation before service.“12 Food safety appears to be replacing nutrition as the consumer health concern of the 19908.13 Major food safety concerns identified by consumers have been food additives and pesticide residues . 11 ' 14' 15 Consumers have two incorrect perceptions about food safety: the degree of risk from food contamination and reliable sources of information about food safety. These inaccuracies could affect their food handling behaviors. Studies have shown that consumers sustain minimal health risk 28 PL he th f 1'1 tax (AI r914 heal 29 from the effects of pesticide residues in foods.7 However, pesticide residues in foods are widely held to be a significant risk factor. The regulatory sector ranks microbiological hazards as the major issue in food safety.1'11'15'16 Industry representatives also share that view. One recent survey“ asked major food processors to rank potential food hazards. The results of the survey showed that microbiological hazards topped the list, with 91% of respondents considering microbiological hazards to be of high-to-medium importance. Consumers need to be educated about the impact on their health of microbiological hazards from improperly handled foods. In regard to the second perception, consumers believed that health professionals, such as physicians and nurses, can provide reliable food safety information.3 Indeed, health professionals have many opportunities to provide information on food safety to consumersula IHowever, many HIPs affiliated with local health departments, such as health educators, public health nurses, public health nutritionists and public health physicians, pay less attention to foodborne disease in the 1990 than they did in the past.“ Most human and financial resources of local health departments currently target the prevention of acquired immunodeficiency syndrome (AIDS) and venereal diseases, pandemics (tobacco- and alcohol- related illnesses and deaths), poverty and its attendant health problems, and issues of priority (immunization versus 30 transplantation, rationing of care) .20 These issues are perceived as more critical public health issues than food safety. A research study reported consumers underutilized local health department services.3 Over 40% of the respondents never used such services. Increasing consumer awareness about the availability of these services could be an.important.means to‘develop local health.departments.as a source of food safety knowledge. ‘Various groups of HIPs ihave been. evaluated in the particular competencies of their specialties?“26 However, information about assessment of HIPs' knowledge of safe food handling was not found in the literature. Accordingly, the purpose of this study was to assess the safe food handling knowledge of HIPs and to determine their training needs in this area. HIPs working in local health departments in Michigan were used as the sample population. 3.3 Method Mailed surveys to HIPs were used to obtain information on their knowledge of safe food handling. 3.3.1 Description of the Sampling Frame HIPs affiliated with local health departments in Michigan made up the sampling frame for this research. HIPs were affiliated with Michigan health departments. Specific professional groups included foodservice sanitarians, health educators, public health.nurses, public health nutritionists, and public health physicians. 3.3.2 Development of the Questionnaire The objective of the questionnaire was to determine HIPs' knowledge of safe food.handlingu The questionnaire contained 26 questions in two areas: demographics and knowledge of safe food handling. 3.3.2.1 Demographics The demographic questions covered three areas: (1) respondent characteristics--age, gender, years in specialty area, residential setting, race, educational level and household income; (2) types of interactions with children on safe food handling; and (3) sources of safe food handling information. 31 3E Va C0 the the Val dis 32 3.3.2.2 Knowledge of safe food handling Knowledge questions were developed based on the results of earlier studies which found that consumers lacked knowledge about time and temperature effects on Contamination, sources of contamination, and cooling procedures.“ Eight questions were developed to determine the respondent's knowledge about safe food handling. The questions were developed to cover the four constructs critical to the prevention of foodborne disease: food temperatures and storage, personal hygiene, cross-contamination, and the identification of potentially hazardous foods . 24"": ‘2' “'27-” The content, construct, and face validity of the questionnaire were assessed by reviewers with expertise in these fields: food safety and surveys. Content validity in this research was assessed by determining whether the questions chosen were accurate (right answers were correct; wrong answers were incorrect) .29 Face validity was assessed by expert reviewers, which determined whether the survey was appropriate for the intended population.” Construct validity was assessed according to whether the items represented the concept (safe food handling) they were intended to measure.29 The questionnaire was pilot-tested with a subsample of the population (n=49) to determine the criterion validity and the difficulty level of the knowledge items. Criterion validity in this research referred to whether the instrument discriminated between masters and non-masters of the 33 information represented by the construct.29 The discrimination index was used to assess criterion validity and was calculated for individual items and for the total survey. The index of discrimination used in this item analysis was calculated as the difference between the proportion of the high scorers (upper 27%) who selected the correct answer minus the proportion of the lower scorers (lowest 27%) who selected the right answer. An item discrimination of greater than 0.33 was the standard for acceptability in this study. The difficulty index (proportion of the total group who selected the correct response) was also calculated. A high index indicated the item was easy and a low index indicated that the item was difficult.29 Both the discrimination and difficulty' indices for ‘the survey' were acceptable (mean difficulty-0.79; mean discrimination=0.37). The results of the pilot test showed the Kuder-Richardson reliability coefficient for the knowledge items was 0.29. The questionnaire was also reviewed and approved by the University Committee on Research Involving Human Subjects (UCRIHS) at Michigan State University in March 1991. 3.3.3 Obtaining the Samples In September 1991, a project statement requesting participation in the present study (Appendix 1), a reply card (Appendix 2), and a sample questionnaire (Appendix 5) were sent to the health officers of all local health departments Cu ax de Wh (A 34 (N=48) in Michigan. The health officer is usually the administrative head of a local health department. The project request had the endorsement of the Michigan Association for Local Public Health (MALPH). Foodservice sanitarians, health educators, public health nurses, public health nutritionists, and public health physicians at local health departments were invited to participate in the study. Fifty percent (n=24) of the health officers of local health departments in Michigan agreed that their health departments would participate. The total number of questionnaires requested by participating local health departments was 891--252 for foodservice sanitarians, 80 for health educators, 81 for public health nutritionists, 424 for public health nurses, and 54 for public health physicians. 3.3.4 Mailing Questionnaires for all HIPs at each public health department were sent by bulk mail. Prepaid return postage was enclosed in an attempt to increase the response rate.30 Mailed questionnaires were coded in alphabetical order by the county in which the local health department was located. Questionnaires (n=891) were mailed between September 20, and October 20, 1991. Each. participating local health department (n=24) was mailed a box (37 cm x 27 cm x 27 cm) which included a cover letter (Appendix 3), a return sheet (Appendix 4), and the number of questionnaires requested by 35 the health officer on the reply postcard. The cover letter emphasized the importance of participation and its value to the HIPs. Confidentiality was ensured. 3.3.5 Statistical Analyses Data were analyzed using the Statistical Package for the Social Sciences (SPSS/PC+, version 4.0) . The following analyses were conducted: mean, standard deviation, frequency distribution, and a five-way analysis of variance to determine the differences in knowledge of food handling by respondents' gender, age, years in specialty area, formal training on safe food handling, and educational level. A probability of p g .05 was used as the level of significance for all analyses. 3.4 Results and Discussion The purpose of this study was to assess the safe food handling knowledge of HIPs and to determine their training needs in this area. Fifty percent (n=24) of local health departments in Michigan (N=48) participated in the study. HIPs (n=891) affiliated with local health departments who received questionnaires were: foodservice sanitarians, health educators, public health nurses, public health nutritionists, and public health physicians. The questionnaires were mailed during October 1991 and returned no later than November 15, 1991. 3.4.1 Response Rate Questionnaires (n=891) were sent to the designated contact person(s) of the 24 participating local health departments in Michigan. Nearly 70% of mailed questionnaires (n=611/891; 68.5%) were completed and returned. Response rates by group of HIPs for all questionnaires (n=891) mailed are provided in Table 3.1. Of the five groups of HIPs surveyed, the highest response rate was from foodservice sanitarians (84.9%); the lowest response rate was from public health physicians (44.4%) (Table 3.1). The percent of the total sample population by HIP group is shown in Figure 3.1. Public health nurses represented the 36 37 .wcsum was» ca muscwofiuumc ou pounce musmauusmmc spasms Hmooa savanna: we no em .H m.mm Ham Ham HOHOB ¢.¢¢ _ em em mceaowmhnm spasm: Owansm m.mb He no umeOHuwuuaz spasm: Owansm n.Hw com «me mmmuaz EHHMOE Owanam o.mw mm on muouoosum nuammm m.vw ¢H~ «mm mcswumu«smm 00fi>ummcoom va cocksumm uswm umcw>oum coausauoucH Guam mmcommwm Illmwuflmmdmdumwmdlllll spasm: advance: «0 Ozone .vmucv amuswauumawc spasms HMOOH savanna: cuw3 cousaawuun Aamwucv mumcq>ouc coHusfiuomsw guano: uo mmsouo m>wm ou omafioa mafiaccmc coon mama so chaoscowummsu c you mousu Omsocwwm H.n manna 38 - Key: Health information provider groups: FS: Foodservice sanitarians (n=214) HD: Public health nutritionists (n=61) HE: Health educators (n=52) HN: Public health nurses (n=260) HP: Public health physicians (n=24) Figure 3.1 Percent of total respondents (n=611) represented by each of five groups of Michigan health information providers. Health information providers were affiliated with local health departments that responded to a mailed questionnaire on safe food handling in 1991. 39 largest sample of respondents (42.6%), followed by foodservice sanitarians (35.0%) , and public health nutritionists (10.0%) . 3.4.2 Demographics Demographic characteristics of HIPs who responded to the questionnaire on safe food handling are summarized in Table 3.2 and Appendices 5-10. Respondents from local health departments were predominantly female (71.8%) and white (80.7%) . The respondents ranged in age from 21 to 70 years of age, with a mean (1 standard deviation) age of 39.519.9 years. Length of time in their specialty area ranged from less than one year to 40 years, with a mean (1 standard deviation) of 9.8:8.4 years. Over half the respondents (59.2%) had at least a bachelor's degree; 18.0% had a higher degree. Only one- fifth of HIPs (20.9%) had received any formal training in safe food handling during 1991. Of the five groups of HIPs, foodservice sanitarians most frequently received formal training on safe food handling during 1991 (51.4%). Health educators received the least formal training on safe food handling (3.8%) . Over half of the public health nutritionists (50.8%) were registered dietitians (H.D.) , and 57.7% of public health nurses were registered nurses (R.N.) . Eight percent of surveyed foodservice sanitarians were registered sanitarians (3.5.). 40 coauea>ev caduceu- H sees ”and .n .nsoaueesu Add assess no: can ouceccomnou 080m monsoon moaunauouoeueno oqsmeuooeov ocean nodue> announce usoouon Hauoa .n neeusc guano: oaansm «z: ououeosco guano: an: oceaueuqcen ooa>uonc00m «mu acuaoausgd guano: change ”an uuuacoqusuuac guano: oaansa ”on o.ooa m.mm H.wm b.om N.om M.Mm deuce N.¢m v.mm n.um H.N> m.bh b.0m ends: o.o o.o o.o o.o o.o n.o deacon o>auez «.4 o.o o.o 6.3 a." 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Almost ninety percent (89.6%) of all HIPs‘ considered safe food handling to be the "most important" or "as important as most" other things they do to maintain their health (Table 3.2). Only 1.0% of respondents replied that they were not familiar with safe food handling methods. Compared to the other groups of HIPs, 11.5% of health educators considered safe food handling to be less important than other things they do to maintain their health. Types of interaction with children about food handling noted by HIPs are listed in Table 3.3. Almost half (48.4%) indicated that they had opportunities to provide children with information about safe food handling, especially public health nutritionists (59.0%) (Table 3.3; Appendix 5, Question 5). The most frequent type of interaction reported was talking to parents or guardians during office visits for their child (26.4%). Sources of information on safe food handling received by HIPs are shown in Table 3.4. Based on results shown in Table 3.4, over half the HIPs (62.2%) responded that newspapers and consumer magazines were the information sources used most frequently for information about safe food handling. Professional or job-related meetings followed with 50.9%, professional journals (50.4%), and government pamphlets 44 uco>o usaxaomu soounuoao can wand» 080: .Hoonoo huuucoeodo c4 ousouom modsoaou nuonuo .« uuoudosvo nuaoom «a: uuuqsoduquuss guano: oaansm an: usuauuudcnn 004>uono00h ”mm ”nooa>oum coauuauOHsa guano: mo nasouu .H ocuaoansam guano: odaaam “as moons: suauon Odansm ”2m n.0m m.wm m.om o.ow n.5n ¢.mv Annoy o.o m.o N.oa o.o v.m n.o wuonuo .b h.on n.~ v.m m.vfl o.o" n.m naoduouua souuau3 ouomoum .0 m.m m.> o.o o.o H.~H o.o Moscoouom auscuudosvo 0» xaua .m couoaaso wanna New unqud> oouuuo o.me s.ov s.m H.mc H.m v.o~ deduce .ucodvuuao. unsound 0» edge .4 umsaauuu huqsseaoo s4 m.m m.HH 5.5 N.n 5.5" m.~a convadno no museum 0» xaaa .n h.oa m.NH m.m m.H m.~ v.5 uuqnw> ooquuo unquso oaqno a 0» xaua .N . mucouum uaonu uo\osd confidano n.0N m.m s.» m.H v.5 n.m on xauu uuoxuozloo ha uuosvom .H nouddldu no souvddno £043 sedan-wound usddvudn each ovum A nonsomuou mo a v .kuc. .oouuc. .umu:. Adena. .camucv .Haonc. ucaaocas mm 2x mm on ma duuoa coca Guam usond souoaAnO HuuuAwammIaa4uqaumuqqlauaquqnumnammum cud: soauoouousd mo onha .HOOH Cd OGHHUCGS ”OOH OHGD CO OHHGGGOHHDOQU pagans a O» poocomuou on: nucoeuuomoo guano: Hanan mo Adam's. uuooq>oum codudauOMcd guano: savanna: >9 vouuomou souoaagu sud: coauOduouca ocqavsun poo“ Qua. «0 nom>a n.m manna 45 come» oovw> use uxoon .co«u«>oaou .uouusoo omoaaoo .OAOmu “nonuo .v .cuauaosnm guano; oaansa .a: nouns: guano: oaanam .zx uuooa>oud ”4 .n nowadauousu guano: savanna: an toququcooa paddocos coo» can. so noduaBMOucu no oousou ouuusouu boos one uuouq>oun couuosuouca guano: savanna: an vouuaucooa caduceus UOOu anon so noduusuOucw no uoouaom ”m .m uuouoosoo nuauox ”u: .uaqcoauouusc guano: oqansm “a: ocnauouacou oo«>uooo00h ”mm .uoo«>oum caduceuOucq guano: uo odaouo .H n.5n m.NH N.vN 5.NH .m.nd m.n~ n.a« m.o 0.5 o.n n.5n «.0 uncommon oz .0” 0.0 n.o o.v H.o 5.5 H.HN o.w v.Hu a.» m.mn v.m H.nn qumcuo .m n.» o.mu 5.5" «.on m.n n.n~ o.o o.ov o.ov u.no 5.4" o.om nonsuooe nouasou no“ no Amcosuuoaoua .m «.mn N.vm o.o" 5.Nn n.5n 5.0m 5qoa v.um H.5N 5.m5 n.a~ v.om neocu50n accoAmnmuoum .5 o.o o.mu «.n n.nn 5.5 m.on o.v a.an v.n v.ed ”.5 m.5H aqocsoo xuqoo savanna: \HucOAumz .o m.«u 5.0m o.o o.ow v.m~ «.mm o.v 5.mm m.a 5.nm m.o ~.«o nocwuoooe unsauc00\uodudu3mz .m 0.0 n.m o.o a.n o.o m.n o.o 0.0 0.0 5.n o.o m.n uoauunau doozou Hmooq .v «.o n.nn n.o n.ow ".5" o.ov H.nn m.mv «.5 n.ww o.oa 5.nv uumaszdm acmecuo>oo .n N.v «.ou o.o n.~n o.o H.ov o.o w.o o.o o.wH m.o v.vn .uocoauu ocm 5Ha6dm .m o.o n.o n.mn o.o“ . v.mn .m.on 5.5a «.vv n.u «.ma o.HH n.5n acq>uom acamcouxm o>aumumdooo .H A noncomoou no a v i i “9.5 a “Mo.,: a £15: um $3.055: an m: a: a: mu auuoa ocaaoco: moan mum» co puuuu4NmHmIaaHunauauddlduddddludlmdmuu caduusuOuCM uo mou=Om .Homa ca caduceus coca own. so ou«nceo«uuosu pagans a o» concomuou on: mucosuunmov guano: HoooH sue; vouoaawuum .nuunc. ouovq>oua coauasuousq guano: savanna: 5n unquaucooq noduosuOucd acadocoz ooou anon no amouaom v.n wanna 46 (43.7%) (Appendix 5, Question 2). Sources of information about safe food handling noted by HIPs were similar to those described by Gravani3 in a national consumer survey. Results of both studies indicated that newspapers and consumer magazines were the most frequent sources of information on safe food handling. Sources of information on safe food handling rated as the most accurate by the respondents are shown in Table 3.4. Almost one-fourth of HIPs (24.9%) believed that professional or job-related meetings provided the most accurate information about safe food handling, followed by professional journals (21.3%), and Cooperative Extension Service materials (11.8%) (Table 3.4, Appendix 5, Question 3). Almost 20% of health educators responded that government pamphlets provided the most accurate information on safe food handling. Both public health nurses (18.1%) and public health nutritionists (19.7%) identified Cooperative Extension Service materials as the most accurate source of information on safe food handling. The HIPs' perception of the most accurate source of information on safe food handling was different from Gravani's findings on consumers' expectations of accuracy.3 Gravani found that 75% of the consumers be surveyed ranked newspapers, magazines, and health professionals as "reliable" or "very reliable" sources of food safety. 47 3.4.3 Knowledge of Safe Food Handling Content of knowledge questions on safe food handling and percent of correct responses by five groups of HIPs are shown in Table 3.5. Ninety-nine percent (99.7%) of respondents across all groups of HIPs correctly identified the refrigerator as the location for proper storage of ground beef (Table 3.5). Among all groups of HIPs surveyed, foodservice sanitarians had a significantly higher mean score (89.4%) on the eight knowledge questions about safe food handling than any other group (Table 3.5) . Public health nutritionists had a statistically significantly higher mean score (79.9%) on safe food handling than did public health nurses (66.8%). The scores of health educators (73.6%) , public health nurses (66.8%), and public health physicians (73.4%) did not differ significantly. 3.4.3.1 Food temperature and storage Nearly 98% of respondents correctly answered the first two questions about methods of storing and thawing ground beef (Table 3.5, Appendix 5, Question 7 and 8). Although almost all HIPs knew that the refrigerator is the safest place to store ground beef and to thaw frozen ground beef, only three- fifths of HIPs (60.9%) knew that 45°F was the maximum safe temperature for the operation of refrigerators." The temperature, 45°F, was chosen as the correct answer to the question on refrigerator temperature because 45°F is still F‘|' I. 023 OUCWEUVQQQU £¥FK0£ Cfimdfiod: EOHU Awlcv UCAHUCGS UOOH.WMQW CO MEGUfi QUUQHBQCk C+ QEECIIII Ill}- 48 uuouoosoo guano: an: ucsdounasm guano: usansm «a: nuaqcodaduuss guano: oaansm no: nouns: guano: oaansm .2: assauoudcsu ooa>uou000h “an “noouboum scandauoHca nouns: uo unsouo .H Aonuom coupon on muoaosmsooou aouu nachos «sooooongmoum uo Houmssuav m.5m m.ow m.w5 m.m5 m.wm w.m5 nodnoflwldunoo alouo .0 lozenmoacnmn no coaumzv n.nm 5.~m _ m.mo m.nm m.Hm o.nm cacao»: Humans-m .m nosuuusoo soaamsm u 5.Hv n.5m m.mn ¢.m5 H.Hm o.om a“ mcoou H0>ouuoa mo onwaadno .v uousuouwuuou mswusuomo so no «.mm o.~m m.Hm m.O5 m.mm o.oo oususuooaou asaaxus ooosossooom .n «.mm 5.5m ~.¢m «.mm H.mm m.5m #005 Dcfi3o£u Hon sawuoooa Hmmm .N o.ooa «.mm o.ooa o.ooa o.ooa 5.mm Home moououm Hon GOHuQOOH umom .H ousuouu can announces.» coon .d A oncommou voouuoo » v lemucv .ommucc .«mncv Aamucv Aqamucv Adamucc mm 2: m: on mm annoy .ucoucooc amuH mmumaaocx nIIImmumuAamuqIaaammaumuqunaudmualumlumqualll .Hmma sw osHHocsn ooou ouwm so ouwosso«umosu coawsa o 09 Uoosonmou on: magmauumdmc span»: Hanna and; counfiafiuun Aflaoucv mumca>oum coaumauoucfi guano: Am no H.mv savanna: scum Amusv msfiaocss poo“ ousm so maova ovoo~3osx ou oncommou uoouuoo unmouom m.n manna .mo.wmv haussoqmasmau acumen no: van .0 .n .sv unuuouuomsu menu on» acquanu scum: .N uuouuosvo guano: «mm uuuqcoauauunc guano: cognam ”a: ncsausuacsa ooa>uon000h ”mu «u0o4>oum coauuBHOuca guano: no unsouo .H acaaudusnm guano: oddnam .mz moons: guano: oqansm «z: onv.m5 49 om.mm onm.n5 hm.m5 ¢~¢.mm m.m5 :00: moms» uo\osn Madam .usmwm M.Mm w.mm o.om o.om m.nm ~.om an ooou muons: no scaunowuuusooH .m 5.Hm m.om m.mw v.nm C.Mm 5.Hm mcmon vowuuom .6 o.ooa v.mm H.wm 5.9m 5.wm v.mm xdwfi Eme no mmMHu .0 5.Hm N.wm o.ooa o.ooa w.mm m.5m umooun noXOAQO vodfioum .Q 5.Hm 5.5m o.vw m.mm o.nm o.mw oumuon cmxom .o m.5n w.mn H.m¢ m.om m.mw o.om 30km coo owuouoon £0H£3 :0 m600h .H nooou uncouUuos hansausouon no so«u¢owudusoon .o A omsommmu uoouuoo « v .vmucv Aoomucv immune “House AeHNucv .HHeucc m: z: m: a: mm Huuoa Ausousoov souH mooodzosx IIIIJmHHudauaMHm1AmwHuHmHaaudawmquammmqlumflhummUMWIll .N no «.6 .coscwucooc m.n manna “56 th( in< 0pc C07 45' re CO Ap th th I'E Re I‘E SC .‘ 50 used as the maximum operating temperature for refrigerators in the publichealth codes of Michigan.31 In a 1974 USDA study“, 49% of respondents indicated that they kept their refrigerators warmer than 40°F. The USDA has indicated that 40°F was the maximum safe temperature for the operation of refrigerators.” Similarly, a recent national consumer survey found that 42% of respondents did not know 45°F was the maximum safe temperature for the operation of refrigerators.3 Half of all respondents (56.0%) knew that a shallow container should be used to chill food rapidly (Table 3.5, Appendix 5, Question 14). However, 23.7% thought the depth of the container was not important. This result is similar to that of a national consumer survey that reported 68% of respondents did not cool stew in a shallow container.3 Results of a 1988 USDA/FDA study indicated that 71% of the respondents used unsafe methods to cool a large pot of stew or soup."‘3 Improper storage and holding temperatures were the most common causes of foodborne disease.“ Information on the proper procedures to cool foods rapidly should be incorporated into a safe food handling education program. 3.4.3.2 Personal hygiene More than three-fourths of HIPs (83.0%) knew that handwashing was important after handling raw chicken (Table 3.5, Appendix 5, Question 10). This finding is similar to that of a 1991 national consumer survey where 83% of 51 respondents reported washing their hands with soap and water after handling chicken.3 IHandwashing can effectively remove transient foodborne pathogens.to prevent the contamination.of food.” According to Feachem,“ the incidence of diarrhea can be reduced by 14 to 48% by simply washing contaminated hands with soap and water for 20 seconds. 3.4.3.3 Cross-contamination Data in Table 3.5 showed that 76.8% of the respondents knew that.staphylococcus aureus is most often introduced into potato salad from food handlers (Appendix 5, Question 12). Food handlers are also an important cause of cross- contamination.7"°'37 3.4.3.4 Identification of potentially hazardous foods Data in Table 3.5 shows that 50.6% of the respondents correctly' selected. the four foods out of six ‘that are potentially’hazardous (Appendix 5, Question 9). "Potentially hazardous food" has been defined as any perishable food that consists in whole or in part of milk or milk products, egg, meat, poultry, fish and shellfish, or other ingredients capable of supporting rapid and progressive growth of infectious or toxigenic microorganisms.” In the present study, 94.6% of the respondents correctly selected two potentially hazardous foods of animal origin-- broiled chicken breast and.skim milk. IHowever, only 50.6% of the respondents identified the other two foods--baked potatoes and refried beans--which also support bacterial growth. 52 Nevertheless, plant foods, such as baked potatoes and rice, have been implicated in outbreaks of foodborne disease.” However, the question was not worded in such a way as to determine whether the respondents knew that plant sources could be a source of bacteria. This supports the need to inform HIPs that any food, whether of plant or animal origin, is a potential vehicle for foodborne disease. In the present study, over 90% of the respondents knew that food such as ham could not necessarily be determined to be spoiled by looking, smelling, and tasting it (Table 3.5, Appendix 5, Question 13). 3.4.4 Statistical Analyses of Knowledge Scores by Demographics Table 3.6 summarizes the effect of the demographic variables of HIPs on their knowledge of safe food handling. Significant differences were determined by analysis of variance (pg .05) . For some analyses, age was categorized into two groups: less than and 40 years or greater than 40 years. This value was selected as the dividing point because it was a median value resulting in development of two groups of equal size. Years in specialty area was categorized into two groups: less than ten years or ten years and more than ten years. This value was selected as the dividing point because it was median value resulting in development of two groups of equal size. Also, educational level was categorized into two 53 .usmowuwsmwm haaoofiundumum no: one: muouosu 03» sun» moon moose m:05uosuous« 50:05: .N Ho.v d "a. mo.v e "e .H mwo.H men. Hnuoa 5mH.H man uouum amsufimom H~.o 5mm.H Q55.H H «a m «5.6 5oH. «NH. H 4 o no.6 Hem. new. H m o .mo.o Hem.m ene.o H 4 5 nn.e ewe. 5HH.H H u 5 ~5.o oMH. omH. H o 5 NH.e ome.~ mwm.~ H d 5 mn.o «m5. mew. H u 5 ..Ho.v ooe.mH on.5H H o a He.o 656. n55. H 5 5 mH.o mom.H mmo.~ H “<5 «mm 5~.o ~n~.H eme.H H Awe coHumosom ..Ho.v Hmo.n~ o5m.5~ H .ov secede e~.o 5oe.H mmw.H H A55 smut 5uHeHomsn :H muum5 ..HHe.v men.~e nnH.~5 H HmmH mcHuso Ase meHeHmue m m ousswm mo moaumfiuouosumno new: ownasumosmo .HmmH :5 0:393: coon omen so ouwsssoaumosu 60.39: s on popsonmou oz: muse—firmness spasm: HMOOH saws ooumaawuus muoofi>oun coauoauousa sudden you msowumosv ooooasosx unmao mo ouoom Houou so muouoou ofisashooaoo mo oosswus> mo mfimhassd o.n manna 54 groups: a bachelor's degree or less or higher than a bachelor's degree. A significant difference in knowledge of safe food handling was found between HIPs who had received training in safe food handling and those who had no formal training during 1991 (p_<_ .01) (Table 3.6) . Respondents who had received formal training in 1991 were more knowledgeable (mean score=92.7%) about safe food handling than were respondents who had not received formal training during 1991 (mean score-76.0%). A significant difference was found between the gender of the respondents and their knowledge of safe food handling (pg .01) (Table 3.6) . Based on the eight knowledge questions, male respondents (n=110) were significantly more knowledgeable (mean score=89.6%) about safe food handling than female respondents (n=234) (mean score=76.3%). The difference in knowledge of safe food handling when respondents received formal training on safe food handling in 1991 was more pronounced with respect to female HIPS than male HIPs (p$.01) (Table 3.6). As shown in Figure 3.2, knowledge of safe food handling was higher for trained (mean score=93.6%) versus untrained females (mean score-72.6%) , whereas knowledge scores of trained (mean score-=92. 1%) versus untrained males (mean score=87.2%) were not significantly different. Although there were no prominent differences in the age and years in specialty areas, the difference in knowledge 55 between the respondents of different age groups differed significantly according to the number of years in their respective specialty areas (p=.02) (Table 3.6). Respondents who were 540 years and.had.210 years work experience were the most knowledgeable about safe food handling (mean score=88.7%) (Figure 3.3). For respondents over 40 years, there was no significant difference in knowledge scores based on the number of years in their specialty area. The primary effect of years in specialty area, educational level, and age was not significant, nor were other interactions examined. 56 TOTAL CORRECT RESPONSES (96) FEMALE MALE GENDER RECEIVED TRAINING - NON-TRAINING Figure 3.2 Histogram of mean knowledge scores of health information providers affiliated with local health departments, by gender and training 57 g (I) m (I) Z 9. so- 8 a: 50‘ '— 8 40- I g i 2' 2° % § 10- 3 c ;.;.;.; ,5 I .;.;.;. Below40 Abovo40 AGE .MORETHAN10YEARS - LESSZTHAN 10YEARS Figure 3.3 Histogram of mean knowledge scores of health information providers affiliated with local health departments, by age and years in specialty area . 3.5 Conclusions and Recommendations Research has shown that U .S. consumers believe that health professionals provide reliable food safety information.3 The results of the present study showed that almost half the HIP respondents (296/611) indicated that they had opportunities to provide people with information about safe food handling. These results, however, also demonstrated that some HIPs were unable to correctly answer questions on safe food handling. They were also unable to identify some potentially hazardous foods. In the present study, HIPs who said they had received training during the previous year had significantly higher scores than those who said they had not. Professional societies to which HIPs belong should increase their emphasis on educational opportunities that focus on safe food handling. Important concepts to include in training are time-temperature relationships as they affect proper food handling and the identification of potentially hazardous foods (Tables 3.7 to 3. 11). Recommendations based on the results of this study of five groups of Michigan HIPs affiliated with local health departments are shown in Tables 3.7 to 3.11. 58 59 Table 3.7 Safe food.handling objectives for further training of foodservice sanitarians affiliated with local health departments who responded to a mailed questionnaire on safe food handling in 1991. _ Objectives Rationale I 1. Personal hygiene Foodservice sanitarians will be able to recognize recommended handwashing procedures which can decrease the risk of foodborne disease. Identification of potentially hazardous foods 2. Foodservice sanitarians will be able to identify potentially hazardous foods. 1. Because 18.2% (39/214) of foodservice sanitarians were unable to correctly answer the question on handwashing procedure (Table 3.5; Appendix 6, Question 10). 2. Because 34.1% (73/214) of foodservice sanitarians were unable to identify potentially hazardous foods (Table 3.5; Appendix 6, Question 9). r 60 Table 3.8 Safe food handling objectives for further training of health educators affiliated with local health departments who responded to a mailed questionnaire on safe food handling in 1991. Health educators will be able to identify recommended refrigerator temperatures and identify appropriate methods to cool leftovers. 2. Identification of potentially hasardous foods Health educators will be able to identify potentially hazardous foods. Objectives Rationale 1. Food temperature and 1. Because 48.2% (25/52) storage of health educators did not know the highest safe temperature of an operating refrigerator (Table 3.5; Appendix 7, Question 11). Because 61.5% (32/52) of health educators were unable to correctly answer the question on refrigerating leftovers (Table 3.5; Appendix 7, Question 14). 2. Because 51.9% (27/52) of health educators were unable to identify potentially hazardous foods (Table 3.5; Appendix 7, Question 9). 61 Table 3.9 Safe food handling objectives for further training of public health nurses affiliated with local health departments who responded to a mailed questionnaire on safe food handling in 1991. Objectives Public health nurses will be able to identify recommended refrigerator temperatures and identify appropriate methods to cool leftovers. 2. Identification of potentially hazardous foods Public health nurses will be able to identify potentially hazardous foods. Rationale 1. Food temperature and 1. Because 68.0% (177/260) storage of public health nurses did not know the highest safe temperature of an operating refrigerator (Table 3.5; Appendix 8, Question 11). Because 72.7% (189/260) of public health nurses were unable to correctly answer the question on refrigerating leftovers (Table 3.5; Appendix 8, Question 14). 2. Because 60.4% (157/260) of public health nurses were unable to identify potentially hazardous foods (Table 3.5; Appendix 8, Question 9). 62 Table 3.10 Safe food handling objectives for further training of public health nutritionists affiliated with local health departments who responded to a mailed questionnaire on safe food handling in 1991. Public health nutritionists will be able to identify recommended refrigerator temperatures. 2. Cross-contamination Public health nutritionists will be able to recognize situations which involve cross- contamination. 3. Identification of potentially hazardous foods Public health nutritionists will be able to identify potentially hazardous foods. Objectives Rationale 1. Food temperature and 1. Because 29.5% (18/61) storage of public health nutritionists did not know the highest safe temperature of an operating refrigerator (Table 3.5; Appendix 9, Question 11). 2. Because 26.2% (16/61) of public health nutritionists were unable to correctly answer the question on handwashing procedure (Table 3.5; Appendix 9, Question 10). 3. Because 49.2% (30/61) of public health nutritionists were unable to identify potentially hazardous foods (Table 3.5; Appendix 9, Question 63 Table 3.11 Safe food handling objectives for further training of public health physicians affiliated with local health departments who responded to a mailed questionnaire on safe food handling in 1991. Public health physicians will be able to identify recommended refrigerator temperatures and identify appropriate methods to cool leftovers. 2. Identification of potentially hazardous foods Public health physicians will be able to identify potentially hazardous foods. Objectives Rationale 1. Food temperature and 1. Because 41.6% (10/24) storage of public health physicians did not know the highest safe temperature of an operating refrigerator (Table 3.5; Appendix 10, Question 11). Because 58.3% (14/24) of public health physicians were unable to correctly answer the question on refrigerating leftovers (Table 3.5; Appendix 10, Question 14). 2. Because 62.5% of public health. physicians were unable to identify potentially hazardous foods (Table 3.5; Appendix 10, Question 9). (15/24) 10. 11. 12. 13. 14. 15. 3.6 References Beran GM. Food safety -- an overview of problems. Dairy, Peod and Envir. Sanit. 1991; 11:189-194. Hecht A. The unknown dinner guest: preventing food-borne illness. FDA Consumer 1991; 25:18-25. Gravani R, Williamson D, Blumenthal D. What do consumers know about food safety? FSIS Food Safety Review 1992; Lawson R, Sosin E, Grossman FG. Good health: food poisoning alert! Redbook 1990; 176:46-57. Mossel D. Food safety and the need for public reassurance. Fbod Science and Technology Today 1989; 3:1,2-10. Weinstein B. Are you food safety savvy? Environmental Nutrition 1990; 13:1,6-7. US Department of Agriculture, Food Safety and Inspection Service. Preventing foodborne illness: A guide to safe food handling, 1990. Jacob H. Safe food handling: a training guide for managers of food service establishments. WHO publication, 1989. US Department of Agriculture, Food Safety and Inspection Service. FSIS Facts, Preventable foodborne illness, FSIS- 34 Hay, 1989, 1-10. Holmes S. The hazards of healthy eating. Nursing Times 1989; 85:49-51. Wolf ID, Lechowich RV. Current issues in microbiological food safety. Cereal FOods WOrld 1989; 34:468-472. Hunter BT. Foodborne illness: a growing problem. consumer Research Magazine 1987; 70:11-14. Adams CE, Sachs S. Government's role in communicating food safety information to the public. Fbod Tech. 1991; 45:254- 255. Huang CL. Consumer perception of food safety. Dairy, Fbod and Envir. Sanit. 1992; 12:495-498. Albrecht JJ. Business and technology issues in U.S. food science and technology. Food Tech. 1986; 40:122-127. 64 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 65 Sachs S, Custer C, Levine P, et a1. USDA, FSIS. A margin of safety: The HACCP approach to food safety education. United States Department of Agriculture, Washington, D.C., 1989. Swintek RJ. New products are king. Food Proc. 1991; 52:38- 40e ‘ Valente C, Sobal J, Muncie HL Jr., Levine D, Antlitz A. Health promotion: Physicians' belief, attitudes and practice. American JOurnal of Preventive Medicine 1986; 2:82-88. Michigan. Michigan public health code: Act 368 of 1978, as amended. Department of Management and Budget, General Services Section, Lansing, 1987. Houston TP. The roots of public health. J. Family Practice 1991; 32:257-258. Hatfield TH. The failure of sanitarians. J. of Envir. Haalth 1991; 53:23-24. Williams AR, Davis RC, Hale CD, Collins TR. Patterns of concern: needs assessment and continuing education needs among public health physicians. The JOurnal of Continuing Education in the Health Professions 1989; 9:131-139. Weinstein E. Health educators: where are you? Health Education 1989; 19:21-22. Sandoval WM, Mueller HD. Nutrition education at the work site: a team approach. J. Am. Diet. Assoc. 1989; 89:543- 544. Gantt JM, Terrell EL. External Evaluation of CDC Homestudy course 3010-G "Community Hygiene." JOurnal of Envir. Health 1987; 49:348-353. Reynolds B, Ried LD. Factors associated with public health nurses' perception of skill in chemical dependency assessment and referral. JOurnal of Drug Education 1985; 15:23-32. Koury SD. Food Sanitation and safety study course, 2nd edition. Iowa State University Press, Ames, Iowa, 1989. Bryan F. Risks of practices, procedures and processes that lead to outbreaks of foodborne diseases. JOurnal of FOod Protection 1988; 51: 663-673. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 66 Carmines EG, Zeller RA. Reliability and validity assessment. Sage Publications, Inc. Beverly Hills, CA. 1985. Dillman DA. Mailing and telephone surveys: the total design methods. John Wiley & Sons, New York, NY. 1978. MEHA (Michigan Environmental Health Association). Michigan's Food Service Sanitation Regulations. 1989. Food Storage P.17-19. Weimer J. and Jones J. Food safety: attitudes and practice. USDA Report No. 360, 1977. US Department of Agriculture, Food Safety and Inspection Service. Results of the Food and Drug Administration's 1988 Health and Diet Survey, Food Handling Practice and Food Safety Knowledge of Consumers, May 1991, 24 pgs and appendices. Bean NH, Griffin PM, Goulding JS, Ivey CB. Foodborne disease outbreaks, 5-year summary, 1983-1987. JOurnal of Fbod Protection 1990; 53:711-728. Paulson DS. Education of three handwashing modalities commonly in the food processing industry. Dairy, Fbod and Envir. Sanit. 1992; 12:615-618. Feachem RG. Interventions for the control of diarrheal diseases among young children: Promotion of personal and domestic hygiene. Bull. WOrld Health Org. 1984; 62:467- 476. Harrington RE. The role of employees in the spread of foodborne disease - food industry views of the problem and coping strategies. Dairy, Fbod and Envir. Sanit. 1992; 12:62-63. Food and Drug Administration. Retail Program Information Manual, Part 6, Center for Food Safety and Applied Nutrition, Retail Food Protection Branch, HFF-342, 1986. Bean NH, Griffin PM. Foodborne disease outbreaks in the United States, 1973-1987; pathogens, vehicles, and trends. J. Food Protect. 1990; 53:804-817. 4.0 Michigan Family Practice Physicians: Knowledge of Safe Food Handling 4.1 ABSTRACT Background. This study was one component of a Michigan statewide assessment that evaluated food handling knowledge of the following populations: third-grade children and their household members, third-grade teachers, school foodservice personnel, and health information providers including family practice physicians. Method. Fifty percent (n=650) of the names on the active membership list of the Michigan Academy of Family Physicians (MAFP) were randomly selected to participate in the study. Questionnaires with eight knowledge items on safe food handling and 18 demographic items were mailed to the family practice physicians during October, 1991. Results. The response rate was 19.8%. Most respondents were male (70.5%) and white (86.8%), with a mean age of 41 years. Although only 1.6% of the respondents had received any formal training in safe food handling during 1991, almost 40% indicated that they had had opportunities, such as office visits, to provide people with information about safe food handling. A significant difference (p=.02) in safe food handling knowledge was found between men and women. Conclusions. The results indicated that additional education on safe food handling is needed which focuses on time- temperature relationships on food handling and the identification of potentially hazardous foods. 67 4 . 2 INTRODUCTION Foodborne disease has been a significant health concern in the United States for many decades and continues to be a problem into the 19903. In 1961, the Communicable Disease Center (since renamed the Centers for Disease Control or CDC) became responsible for maintaining records and reporting foodborne diseases in the United States.‘ Currently, approximately 24-81 million cases of foodborne diseases are estimated to occur in the United States each year.2 Unlike many types of disease, foodborne disease is almost 100% preventable through safe food handling. Thirty percent of all reported foodborne diseases resulted from unsafe handling of food in the home.’ A 1991 national survey showed that consumers ranked the home third (after food manufacturing facilities and restaurants) as the site where food safety hazards were most likely to occur.‘ Some researchers have suggested that foodborne disease can be prevented if food is handled safely, especially during the final stages of preparation before service.5"3 In recent years, Americans have become increasingly concerned about the effect of pesticide residues, and additives in foods.“ However, this perception is not correct. American consumers have not yet become aware of the high risk from microbiological hazards of food that was not handled safely. 3'” 68 69 Although the public perceives physicians as credible sources of health information,""“"17 results of other studies have indicated that their knowledge of food and nutrition might be inadequate or outdated.‘°‘22 ‘ Research in this area supports the possibility that nutrition education in medical school may be a variable influencing the physician's food and nutrition knowledge.” White et al.23 found that physicians obtained most of their nutrition education from postgraduate study and experience in practice. According to Murphy,“ physicians' opinions about nutrition can be influenced positively by some type of nutrition education intervention, such as a seminar series during postgraduate training. This may suggest that physicians are more likely to be influenced favorably when nutrition education occurs in a residency or fellowship program than they are after beginning practice. Many studies have indicated that nutrition receives insufficient attention in medical school curricula.25'2° Two surveys reported that 61%27 and 67%,2° respectively, of graduating medical students believed inadequate time was devoted to nutrition education. The nutrition education provided was sporadic and poorly organized in many medical schools and residency programs.2°'30 Family practice physicians are trained in their specialty in formal three-year residency programs. They are expected to learn how to evaluate total health needs, to provide personal 70 medical care within one or more fields of medicine, to refer patients when necessary and, at the same time, maintain a continuity of care.31 Also, family practice physicians treat 85 to 90% of a patient's health care needs within their clinics.31 Equally important, their training teaches them to practice "preventive" medicine. Physicians practicing in various specialties have been shown to have inadequate knowledge in food-related areas, such as nutrition.18'22 However, specific information on family practice physicians' knowledge of safe food handling was not found in the literature. Thus, the purpose of the present study is to assess the safe food handling knowledge of family practice physicians and to determine their training needs in this area. Family practice physicians were selected for this study because they are an adult population whose knowledge could have an impact on people. 4 . 3 METHODS Mailed surveys to Michigan family practice physicians were used to obtain information on their knowledge of safe food handling . 4.3.1 Description of the Sampling Frame In 1986 family practice physicians represented 11.9% of the total number of 569,160 physicians in the United States.32 In terms of size, family practice ranked second among all physician specialties. According to a 1987 American Academy of Family Physicians (AAFP) Practice Profile Survey,33 93.5% of family practice physicians were engaged in direct patient care. The Michigan Academy of Family Physicians (MAFP) is the association of doctors of medicine and osteopathy who are engaged in family practice in the state of Michigan.34 The goals of the MAFP are (1) to work constantly to maintain and improve high standards of family practice; ( 2) to promote the science and art of medicine and surgery and the betterment of public health and to preserve the patients' right to free choice of physicians; and 3) to acknowledge and assume responsible public advocacy in all health-related matters. As in the AAFP there are seven types of MAFP memberships: student, resident, active, affiliated, sustaining, inactive, and life members.35 Active members make up the bulk of 71 72 Academy membership. To be eligible for active membership, a candidate must be a graduate of a school of medicine or osteopathy, hold a certificate of qualification recognized by the American Medical Association, or hold the degree of doctor of osteopathy and have completed a three-year family practice residency. The primary obligation of active membership is fulfillment of 150 hours of continuing study acceptable to the Commission on Continuing Medical Education (CME) during the preceding three years. This guarantee of competence is met through various CME programs. Active members of the MAFP made up the sampling frame. Family practice physicians treat 85 to 90% of a patient's health care needs within their unique environment. Equally important, their training teaches them to practice "preventive" medicine. This study hypothesized that family practice physicians were in a position to provide primary care and information about safe food handling to children and adult family members during office visits for the treatment of foodborne disease. 4.3.2 Development of the Questionnaire The objective of the questionnaire was to determine family practice physicians' knowledge of safe food handling. The questionnaire contained 26 questions concentrated in two areas: demographics and knowledge of safe food handling. 73 4.3.2.1 Demographics Demographic questions focused on two areas: personal and professional. Personal demographics were defined as age, gender, race (optional), residential ' setting, and household income (optional). The personal demographic information was linked (below) to their personal knowledge of and attitudes about safe food handling practices. Professional demographics were defined as length of time in family practice, educational level, and professional registration (M.D. or D.O.). These demographics were linked (below) with their opinions about current, accurate sources of safe food handling information, training on safe food handing received during 1991, and ‘type(s) of interaction(s) with children on safe food handling. 4.3.2.2 Knowledge of safe food handling Knowledge questions were developed based on the results of earlier studies which found that consumers lacked knowledge about time and temperature relationships to food safety, sources of contamination, and proper cooling procedures.36 Eight (8) questions were developed to determine the respondent's knowledge about safe food handling. The questions were developed to cover the four constructs critical to the prevention of foodborne disease: food temperatures and storage, personal hygiene, cross-contamination, and the identification of potentially hazardous foods.3"8'13'35'38 74 The content, construct, and face validity of the questionnaire was assessed by reviewers with expertise in these fields: food safety and surveys. Content validity in this research was assessed by determining whether the questions chosen were accurate (right answers were correct; wrong answers were incorrect).39 Face validity was assessed by expert review which determined whether the survey was appropriate for the intended population.39 Construct validity was assessed by determining if the questions represented the concept (safe food handling) they were intended to measure.39 The questionnaire was pilot-tested with a subsample of the population (n=30) to determine criterion validity and difficulty level. Criterion validity in this research referred to whether the instrument discriminates between masters and non-masters of the information represented by the construct.39 The discrimination index was used to assess criterion validity and was calculated for both individual items and the total survey. The index of discrimination used in this item analysis was calculated as the difference between the proportion of the high scorers (upper 27%) who selected the correct answer minus the proportion of the lower scorers (lowest 27%) who selected the right answer. An item discrimination index of greater than 0.33 was the standard for acceptability in this research. The difficulty index (proportion of the total group who select the correct response) was also calculated.39 A high 75 index indicated the item was easy and a low index indicated that the item was difficult. Both the discrimination and difficulty indices for the survey were acceptable (mean difficulty-0.72; mean discrimination=0.38). Results of the pilot test showed the Kuder-Richardson reliability coefficient for the knowledge items was 0.42. The questionnaire was approved for use with the specified population by the University Committee on Research Involving Human Subjects (UCRIHS) at Michigan State University (MSU) in March 1991. 4.3.3 Obtaining the Samples After approval of the questionnaire use and content by MAFP in August 1991, a list of addresses of all MAFP active members (n=1,300) was received by MSU during October 1991. Fifty percent (50%) of family practice physicians were randomly selected (every other name from the MAFP active member lists) to participate in the study (n=650 of 1,300 physicians). 4 . 3 . 4 Mailing Questionnaires (n=650) to MAFP members were coded numerically by zip codes and mailed in bulk (October 12 and Returned mail was collected, addresses November 14, 1991). and a second mailing was sent to those were corrected , individuals. A cover letter requesting participation in the study (Appendix 11) and one questionnaire (Appendix 5) were 76 sent to each family practice physician (n=650) with a return envelope (33 cm x 26 cm). Return postage was not included. The1cover letter emphasized the importance of the data and its value to family practice physicians. Confidentiality was guaranteed. 4.3.5 Statistical Analyses Data was analyzed using the Statistical Package for the Social Sciences (SPSS/PC+, version 4.0) . To evaluate the study purpose, the following analyses were conducted: mean, standard deviation, frequency distribution, and a three-way analysis of variance to determine the differences in knowledge of food handling by the respondents' gender, age, and.years in family practice. A probability of pg .05 was used as the level of significance for all analyses. 4.4 RESULTS and DISCUSSION Fifty percent (n=650) of MAFP active members (n=1,300) were randomly selected to participate in the study. The questionnaires (n=650) were mailed during October 1991 and returned by December 14, 1991. 4.4.1 Response Rate Of 650 questionnaires sent to family practice physicians, 129 physicians filled out and returned the questionnaires. The response rate was 19.8%. The response rate of <20% may indicate that only physicians who were interested in safe food handling responded. Researchers suggested that a higher survey response rates are usually obtained if project resources and the project timeline permit use of: return postage for questionnaires, reminder cards for nonrespondents, and repeated survey mailings.‘“’"‘1 4.4.2 Demographics Information on the personal and professional demographics of family practice physicians in Michigan is described below. 4.4.2.1 Personal demographics Personal demographic characteristics are summarized in Table 4 .1 and Appendix 12. They were predominantly male (70.5%) , and white (86.8%) . The respondents ranged in age from 21 to 70 years, with a mean + standard deviation age of 77 78 Table 4.1 Personal demographic characteristics of Michigan family practice physicians (n=129) who responded to a mailed questionnaire on safe food handling in 1991 Characteristics No. of responses1 % of responses Gender Male 91 ' 70.5 Female 36 27.9. Total 127 98.42' Age3 (years) 21-30 8 6.2 31-40 64 49.6- 41-50 24 18.6 51-60 19 14.7 over 60 11 8.5 Total 126 97.7 Ethnic (optional) African-American l 0.8 Asian/Pacific Islander 3 2.4 Hispanic 3 2.4 White 121 86.8 Total 128 99.2 Residential Setting Farm - 7 5.4 Lens than 10,000 people 41 31.8 10,000-50,000 people 22 17.1 Suburb, more than 50,000 26 20.2 City, more than 50, 000 32 24 .8 Total 128 99.2 Household Income (optional) s30,001-40,000 3 2.3 $40,001-S0,000 2 1.6 $50,001-60,000 5 3.9 560,001-70,000 3 2.3 $70,001-80,000 13 10.1 590,001-100,000 20 15.5 $100,001 -110,000 8 6.2 $110,001-120,000 10 7.8 $120,001-130,000 6 4.7 $130,001-140,000 1 0.8 $140,001-150,000 6 4.7 $150,001 - more 13 10.1 Did not answer 26 20.2 Total 126 97.7 Compared to most of the things you do to maintain your health, how important is safe food handling? Most important 3 2.3 Important 89 69.0 Less important 33 ’25.6 Not important 0 0.0 Not familiar with methods of 4 3.1 safe food handling Total 125 96.9 1. (129/650)*100t-19.8\ response rate 2. Total percent response varies among demographic characteristics because some respondents did not answer all questions. 3. Mean age I 42.8 1 10.6 years (Mean): Standard Deviation) 79 40.5:10.0 years. Over one-third of the respondents (37.2%) lived in a town of less than 10,000 people. One third of the respondent's (33.4%) had an annual household income between $70,001 and $100,000. Over 70% of the respondents considered safe food.handling'tolbe‘the "most important" or "as important as most other" things they do to maintain their personal health. Approximately one-fourth of the respondents (25.6%) considered safe food handling to be "less important" than other things they do to maintain their personal health. 4.4.2.2 Professional demographics Professional demographic characteristics are summarized in Table 4.2. The length of time in family practice ranged from less than one year to 46 years, with a mean 3 standard deviation of 12.4:10.9 years. Only 1.6% of all respondents received any formal training in safe food handling during 1991. Over 95% of the respondents had at least a bachelor's degree. The majority of the respondents (82.9%) were Doctors, of Medicine; and 16.3% of the respondents were Doctors of Osteopathy. Types of interaction on safe food handling with children noted by family practice physicians are listed in Table 4.2. Almost 40% indicated that they had had opportunities to provide people with information about safe food handling (Table 4.2, Appendix 12, Question 5). The most frequent type of interaction reported was talking to parents or guardians during office visits for their child (30.2%). 80 Table 4.2 Professional demographic characteristics of Michigan family practice physicians (n=129) who responded to a mailed questionnaire on safe food handling in 1991. Characteristics No. of responses1 \ of responses Length of time in family practice2 1-10 76 58.9 11-20 23 17.8 21-30 15 11.6 over 30 13 10.1 Total 127 98.43 Training Received 2 1.6 Not received 86 66.7 Total 88 68.3 Educational level B.S. 123 95.3 M.S. 4 3.1 Ph.D. 1 0.8 Total 128 99.2 Professional Registration Doctor of Osteopathy (0.0) 21 16.3 Doctor of Medicine (M.D) 107 82.9 Total 128 99.2 Type of interaction with children about safe food handling 1. Request by co-workers talk to 5 3.9 children and/or their parents 2. Talk to a child during office visits 24 18.6 3. Talk to groups of children 5 3.9 in community settings 4. Talk to parents (guardians) during 39 30.2 office visits for their children 5. Talk’to educational personnel 2 1.6 6. Other 1 ‘0.8 Total 50 38.8 Source of information on safe food handling 1. Cooperative Extension Service 14 (9) 10.9 (7.0)5 2. Family and friends 43 (3) 33.3 (2.3) 3. Government pamphlets 21 (S) 16.3 (3.9) 4. Local school district 6 (1) 4.7 (0.8) S. Newspaper/consumer magazines 65 (9) 50.4 (7.0) 6. National] Michigan Dairy Council 16 (3) 12.4 (2.3) 7. Professional journals 56 (41) 43.4 (31.8) 8. Professional or job related meetings 16 (1) 12.4 (0.8) 9. Other 6 (2) 4.7 (1.6) 10. No response 41 (55) 31.8 (42.6) I. (I297658)‘IOO%=19.8\ response rate 3. 4. S. 6. Number of years in practice I 12. 4 + 10. 9 years (Mean + Standard Deviation) Total percent response varies among demographic characteristics because some respondents did not answer all questions. Other- Question at time of history asking information gastroenteritis symptoms Number in parentheses was represented the percent of Michigan family practice physicians rated the most accurate source of information on safe food handling Other: television, books and public health departments 81 Sources of information on safe food handling received by family practice physicians are listed in Table 4.2. As shown in Table 4.2, 50.4% responded that newspapers and consumer magazines were their most frequent information source about safe food handling, followed by professional journals (43.4%) , and family and friends (33.3%) (Appendix 12, Question 2). Sources of information about safe food handling were similar to those of U.S. consumers in 1991.4 Results of both studies indicated that newspapers and consumer magazines were the most frequent source of information on safe food handling. However, one-third of family practice physicians also received information on safe food handling from their family and friends. Ely42 and Covell“3 observed physicians accessing information sources to solve patient problems. Their results showed that physicians were most likely to consult a human source (such as another physician, or other type of health professional) rather than a printed source because of the time required to read. Sources of information on safe food handling rated as "the most accurate" by family practice physicians are listed in Table 4.2. Approximately one-third of the respondents (31.8%) believed that professional journals provided the most accurate information on safe food handling, followed by newspaper and consumer magazines (7. 0%) , and Cooperative Extension Service materials (7.0%) (Table 4.2, Appendix 12, Question 3). However, over 40% of the respondents did not ider hand sou: cons ran) pre: bel: inf< 4.4 Con: cro: haze 4.4. Shot App. kne. stOI (51. ten; ch08 temp 82 identify a "most accurate source of information on safe food handling." The respondents' perception of the most accurate source of information on safe food handling was different from consumers' perceptionn‘ Gravani found that 75% of consumers ranked newspapers, magazines, and health professionals as "reliable” or ”very reliable" sources of food safety.‘ In the present study, nearly one-third of the respondents (31.8%) believed that professional journals provided the most accurate information on safe food handling. 4.4.3 Knowledge of Safe Food handling Table 4.3 lists the eight knowledge questions by construct: food temperature and storage, personal hygiene, cross-contamination, and the identification of potentially hazardous foods. 4.4.3.1 Food temperature and storage Almost 90% of the respondents knew that ground beef should be stored and thawed in the refrigerator (Table 4.3, Appendix 12, Questions 7 and 8). Although the respondents knew that the refrigerator is the safest place in which to store food and to thaw frozen food, only half the respondents (51.2%) knew that 45°F was the maximum safe operating temperature for refrigerators.“ The temperature, 45°F, was chosen as the correct answer to the question on refrigerator temperature because 45°F is still used as the maximum operating 83 Table 4.3 Percent correct response to knowledge items on safe food handling (n=8) from Michigan family practice physicians (n=129) who responded to a mailed questionnaire on safe food handling in 1991. Construct/Knowledge Item % correct responses A. Food temperature and storage 1. Best location to store fresh, raw 98.4 ground beef overnight 2. Best location to safely thaw frozen, 89.9 raw ground beef 3. Recommended maximum temperature 51.2 of an operating refrigerator 4. Chilling of leftover foods in 24.0 a shallow container B. Personal hygiene 81.4 (Method of handwashing) c. Cross-contamination 73.6 (Transfer of Staphylococcus aureus from foodhandlers to potato salad) D. Identification of potentially hazardous foods 1. Foods on which bacteria can grow 38.0 a. Baked potato 89.9 b. Broiled chicken breast 99.2 c. Glass of skim milk 97.7 d. Refried beans 97.7 2. Identification of unsafe food by 93.0 sight, smell and/or taste Mean knowledge score 73.5 84 temperature for refrigerators in the public health code of Michigan.“ In a 1974 USDA study, 49% of the respondents indicated that they kept their refrigerators warmer than 40°F.45 The USDA has indicated that 40°F was the maximum safe operating temperature for refrigerators.36 Similarly, a recent national consumer survey found that 42% of the respondents did not know that 45°F was the maximum safe operating temperature for refrigerators.‘ As shown in Table 4.3, only 24% of the respondents knew that a shallow container (2-inch depth) should be used to chill food rapidly (Appendix 12, Question 14) . This result is similar to a national consumer survey that reported 68% of the respondents did not cool stew in a shallow container.‘ Results of a 1988 USDA/FDA study indicated that 71% of the respondents used unsafe methods to cool a large pot of stew or soup.ls Improper storage and holding temperatures were the most commonly reported causes of foodborne disease.“6 Information on the proper procedures to cool foods rapidly should be incorporated into a safe food handling education program. 4.4.3.2 Personal hygiene As shown in Table 4.3, 81.4% of the respondents knew the importance of handwashing (Appendix 12, Question 10). This finding is similar to that found by a national consumer survey which reported that 83% of the respondents washed their hands 85 with soap and water after handling raw chicken.4 Handwashing can effectively remove transient foodborne pathogens to jprevent contamination of food.47 .According to Feachem,48 the incidence of diarrhea can be reduced by 14 to 48% by simply washing contaminated hands with soap and water for 20 seconds. 4.4.3.3 Cross-contamination Data in Table 4.3 showed that 73.6% of the respondents knew that Staphylococcus aureus is most often introduced into potato salad by food handlers (Appendix 12, Question 12). Food handlers are significant carriers of cross- contamination . 7 ' 8 ' 49 4.4.3.4 Identification of potentially hazardous foods Data in Table 4.3 showed that 38.0% of the respondents correctly selected the four foods out of six that are potentially hazardous (Appendix 12, Question 9) . "Potentially hazardous food" is defined as any perishable food which consists in whole or in part of milk or milk products, egg, meat, poultry, fish and shellfish, or other ingredients that can support the rapid and progressive growth of infectious or toxigenic microorganisms.5° In the present study, 97.7% of the respondents correctly selected the two potentially hazardous foods of animal origin--broiled chicken breast and skim milk. However, only 38% of the respondents identified the other two foods of plant origin--baked potatoes and refried beans--that can support bacterial growth. This finding might indicate that most 86 respondents think that only animal foods and their products can support the growth of pathogenic bacteria. However, plant foods, such as baked potatoes and rice, have been implicated in outbreaks of foodborne disease.51 The question (Appendix 12, Question 9) was not worded in such a way as to determine whether the respondents knew that plant sources could be a source of bacteria. This supports the need to teach family practice physicians that all foods--whether of plant or animal origin--can be vehicles for foodborne disease. In the present study, over 90% of the respondents knew that food such as ham could not be determined to be spoiled by looking at, smelling, or tasting it (Table 4.3, Appendix 12, Question 13). 4.4.4 Statistical Analyses of Knowledge Scores by Demographics Table 4.4 summarizes the effect of the demographic variables of family practice physicians on their knowledge of safe food handling. Significant differences were determined by analysis of variance (p_.05). For some analyses, age was categorized.into two groups: less than 40 years or 40 or more years. This value was selected as the dividing point, because it was median value resulting in development of two groups of equal size. iLength of time in family practice*was categorized into two groups: less than eight years or eight or more years. This value was selected as the dividing point, because 87 .ucsoHuHcmHm hHHsOmeHusun no: owoz ewouosu 03» com» once moose ecoHuosuoucH woomHm .H mmev m fl. e“ 5N5.H HHH HmuOB HHo.H «OH uonum HoouHmom e5.o 50H. n5H. H a» d 50.0 omH. ~mv.m H N U nH.o HHm.H NHn. H d 0 5m.o mmH. mom. H “we 00HuoonmcH masowuo nonasz e~.e omo.H oH5.~ H new one .Hmo.o o-.m mmo.n H nee Hoodoo m 5 chosen so moHumHuouOonsoO coo: OHoomnmoaoo .HmmH cH mcHHccco coon omen so oancsoHumosc cOHHca c on ooucoomon 0:3 mooHonaom ooHuomno aHHaou ccmHoOHS uou msovaosu 0000.235. page no ouoom chou so muouoou OHoocHOoe—ou no confined, no mHmmHssm v4 oHocB 88 it was median value resulting in development of two groups of equal size. The gender of respondents showed a statistically significant effect on their knowledge about safe food handling (Table 4.4, p=.02) . Female respondents (n=32) correctly answered more knowledge questions (mean score=77.0%) on safe food handling than did male respondents (n=80) (mean score=68.0%). The primary effects of age and length time in family practice were not significant, nor were other interactions examined (Table 4.4). 4 . 5 CONCLUSIONS and RECOMMENDATIONS Consumers believe that health professionals can provide reliable food safety information.‘ The present study showed that over one-third of physician respondents (38.8%) indicated that they had opportunities to provide people with information about safe food handling. However, results of the present study showed that some family practice physicians were unable to correctly' answer' questions. on. safe refrigerator temperature, on proper cooling methods, and on the identification of potentially hazardous foods (Table 4.3). Family practice physicians should.be given opportunities to improve their knowledge about safe food handling. Education programs for family practice physicians should include reinforcement of time-temperature relationships to food handling and the identification of potentially hazardous foods. . Family practice physicians should become more aware of people and organizations knowledgeable in the area of safe food handling. Nutritionists and dietitians are an important resource regarding food preparation and handling, but many physicians still do not fully use their expertise. Although the registered dietitian is recognized as the professional most qualified to teach nutrition, only 1% of residency programs employ a full-time dietitian for this purpose.52 A 89 90 need for a greater awareness of and use by physicians of the dietitian's potential as a consultant is indicated. .According to one studyz‘, physicians were more likely to be influenced favorably when food safety and nutrition education occurred before starting office practice. If this is true, dietetic professionals should aggressively seek to collaborate with medical faculties to create medical school and medical residency/ internship food safety and nutrition education curricula. Recommendations for continued education related to safe food handling for Michigan family practice physicians based on these results are provided in Table 4.5. 91 Table 4.5 Safe food handling objectives for further training of Michigan family practice physicians (n=129) who responded to a mailed questionnaire on safe food handling in 1991. — Objectives Rationale 1. Food temperature and storage Family practice physicians will be able to identify recommended refrigerator temperatures and appropriate methods to cool leftovers. 2. Identification of potentially hazardous foods Family practice physicians will be able to identify potentially hazardous foods. 1. Because 48.8t (63/129) of family practice physicians did not know the maximum safe temperature for an operating refrigerator (Table 4.3; Appendix 12, Question 11). Because 76.08 (98/129) of family practice physicians were unable to correctly answer the question on refrigerating leftovers (Table 4.3; Appendix 12, Question 14). 2. Because 62.0% (BO/129) of family practice physicians were unable to identify potentially hazardous foods (Table 4.3; Appendix 12, Question 9). Residency programs Physicians were more likely to be influenced favorably when food and nutrition education occurred Effore starting office Apractice. Food safety professionals such as Registered Dietitians Although the registered dietitian is recognized as the professional most qualified to teach nutrition, only 1% of residency programs employ a full-tin)?2 dietitian for this purpou- 10. 11. 12. 13. 14. 4.6 References Banwart GJ. Basic food microbiology. 2nd edition. Van Nostrand Reinhold publication, New York, NY. 1989. Beran GM. Food safety--an overview of problems. Dairy, Food and Envir Sanit 1991; 11:189-194. Hecht A. The unknown dinner guest: preventing food-borne illness. FDA Cbnsumer 1991; 25:18-25. Gravani R, Williamson D, Blumenthal D. What do consumers know about food safety? FSIS Food Safety Review 1992; 2:12-14. Lawson R, Sosin E, Grossman FG. Good health: food poisoning alert! Redbook 1990; 176:46-57. Mossel D. Food safety and the need.for public reassurance. Fbod Science and Technology Today 1989; 3:1,2-10. Weinstein B. Are you food safety savvy? Environmental NUtrition 1990; 13:1,6-7. US Department of Agriculture, Food Safety and Inspection Service. Preventing foodborne illness: A guide to safe food handling, 1990. Jacob M. Safe food handling: a training guide for managers of food service establishments. WHO publication, 1989. US Department of Agriculture, Food Safety and Inspection Service. FSIS Facts, Preventable foodborne illness, FSIS- 34 May, 1989, 1-10. Holmes S. The hazards of healthy eating. Nursing Times 1989; 85:49-51. Wolf ID, Lechowich RV. Current issues in microbiological food safety. cereal Foods World 1989; 34:468-472. Hunter BT. Foodborne illness: a growing problem. consumer Research Magazine 1987; 70:11-14. Adams CE, Sachs S. Government's role in communicating food safety information to the public. Food Tech 1991; 45:254-255. 92 15. 16. 17 18 19 20 21 22 23 24 25 26 27 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 93 US Department of Agriculture, Food Safety and Inspection Service. Results of the Food and Drug Administration's 1988 Health and Diet Survey, Food Handling Practice and Food Safety Knowledge of Consumers, May 1991, 24 pgs and appendices. Kunkel ME, Cody MM, Davis RJ, Wheeler FC. Nutrition information sources used by South Carolina adults. J Am Diet Assoc 1986; 86:371-372. Dismuke SE, Miller ST. Why not share the secrets of good health? The physician's role in health promotion. JAMA 1983; 249:3181-3183. O'Keefe C, Hahn DF, Betts NM. Physicians' perceptive on cholesterol and heart disease. J Am Diet Assoc 1991; 91:189-192. Sobal J, White-O'Connor B, Muncie Jr. HL. The importance of nutrition topics among family medicine residents and faculty. JOurnal of Nutrition Education 1988; 20:20-22. Winick M. The nutritionally illiterate physician. JOurnal of Nutrition Education 1988; 20:s12-sl3. Sobal J, Muncie Jr. HL, Valente CM, DeForge BR, Levine D. Physicians' beliefs about vitamin supplements and a balanced diet. JOurnal of Nutrition Education 1987; 19:181-185. Krause TO, Fox HM. Nutritional knowledge and attitude of physicians. J Am Diet Assoc 1977; 70:607-609. White PL, Johnson OC, Kibler MJ. Council on Foods and Nutrition, American Medical Association: Its relation to physicians. Postgrad. Med 1961; 30:502-507. Murphy PS. Family physicians' opinions on nutrition after nutrition education. J Am Diet Assoc 1990; 90:1584-1586. Swanson AG. Nutrition sciences in medical-student education. Am J Clin Nutr 1991; 53:587-588. Weinsier et a1. Priorities for nutrition content in a medical school curriculum: a national consensus of medical educators. Am J Clin Nutr 1989; 50:707-712. Physicians for the twenty-first century. The GPEP Report: Report of the Project Panel on the General Professional Education of the Physician and College Preparation for Medicine. J Med Educ 1984; 59:part 11:15-27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 94 McLeod C. Dal grads identify practice areas where they were poorly prepared. Med Post 1989; 19:35. Walsh JH, Dappen A, Gessert C. Factors affecting nutrition training in four family practice residencies. J Am Diet ASSOC 1987; 87:1558-1560. Young EA. Nutrition in medical education. Nutr News 1988; 51:9-11. AAFP (American Academy of Family Physicians). Family practice is a medical specialty. Kansas City, Mo. 1991. Roback G, Mead L, Randolph L. Physician Characteristics and Distribution in the U.S. Chicago, American Medical Association, 1987. AAFP (American Academy of Family Physicians). Facts about family physicians. Kansas City, Mo., Burd & Fletcher Inc. 1987. MAFP (Michigan Academy of Family Physicians). Family ‘medicine: The way it was is not the way it is. Okemos, MI. 1992. AAFP (American Academy of Family Physicians). AAFP membership classification chart. Kansas City, Mo. 1988. US Department of Agriculture, Food Safety and Inspection Service. A margin of safety: The HACCP approach to food safety education. 1989. Koury SD. Food Sanitation and safety study course, 2nd edition. Iowa State University Press, Ames, Iowa. 1989. Bryan F. Risks of practices, procedures and processes that lead to outbreaks of foodborne diseases. JOurnal of Food Protection 1988; 51: 663-673. Carmines EG, Zeller RA. Reliability and validity assessment. Sage Publications, Inc. Beverly Hills, CA. 1985. Shosteck H, Fairweather WR. Physician response rate to mail and personal interview surveys. Public Opinion Q. 1979; 43:206-217. Dillman DA. Mailing and telephone surveys: the total design methods. John Wiley & Sons, New York, NY. 1978. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 95 Ely J, Burch RJ, Vinson DC. The information needs of family physicians: case-specific clinical questions. JOurnal of Family Practice 1992; 35:265-268. Covell DG, Uman GC, Manning PR. Information needs in office practice: are they being met? Ann Intern Med 1985; 103:596-599. ' MEHA (Michigan Environmental Health Association). Michigan's Food Service Sanitation Regulations. 1989. Food Storage P.17-19. Division of Environmental Health, Bureau of Environmental and Occupational Health. Michigan Department of Public Health. 3500 N. Logan, P.O. Box 3005, Lansing, MI. Weimer J. and Jones J. Food safety: attitudes and practice. USDA Report No. 360, 1977. Bean NH, Griffin PM, Goulding JS, Ivey CB. Foodborne disease outbreaks, 5-year summary, 1983-1987. JOurnal of Food Protection 1990; 53:711-728. Paulson DS. Education of three handwashing modalities commonly in the food.processing industry..Dairy, Fbod’and Envir Sanit 1992; 12:615-618. Feachem RG. Interventions for the control of diarrheal diseases among young children: Promotion of personal and domestic hygiene. Bull World Health Org 1984; 62:467-476. Harrington RE. The role of employees in the spread of foodborne disease - food industry views of the problem and coping strategies. Dairy, Fbod and Envir Sanit 1992; 12:62-63. Food and Drug Administration. Retail Program Information Manual, Part 6, Center for Food Safety and Applied Nutrition, Retail Food Protection Branch, HFF-342, 1986. Bean NH, Griffin PM. Foodborne disease outbreaks in the United States, 1973-1987; pathogens, vehicles, and trends. J. Food Protect. 1990; 53:804-817. Nuhlicek DR, Simpson DE, Lillich DW, Borman RJ. Teaching and funding nutrition instruction in family practice education. Acad Med 1989; 64:103-104. 5.0 CONCLUSIONS Research has shown that consumers believe that health professionals can provide reliable food safety information (Gravani, 1992). Data from the current study indicated that 48.4% of HIP respondents (Table 3.4, p.45) and 38.8% of Michigan family practice physician respondents (Table 4.2, p.80) are providing information on safe food handling to people. Information provided by HIPs and family practice physicians may not be always current or accurate. Educational opportunities for learning about safe food handling should be offered to HIPs and family practice physicians on at least a yearly basis. HIPs who reported receiving training during 1991 had significantly higher scores than those who did not report receiving training. Important topics to stress include time-temperature relationships to safe food handling and the identification of potentially hazardous foods (Tables 3.7-3.11 and Table 4.5). Future educational programming should include wider use of the mass media, including newspaper and consumer magazines, because these sources were identified by the respondents as their most frequently used information source. Furthermore, 96 97 the mass media reach.many sectors of the population and would thus be an excellent information resource, if the information presented was accurate. 6 . 0 RECOMMENDATIONS l'OR FUTURE RESEARCH Limitations of this study include: (1) lack of the ability to generalize family practice physician data because of the low response rate (19.8%) ; (2) a limited number of knowledge questions (n=8) on safe food handling; and (3) specific foods were listed on knowledge items, thus limiting the ability to generalize the results (Appendix 5, Questions 7, 8, 9, 10, 12 and 13). In the course of conducting this research, both in the field and in reviewing the literature, ideas for future study were developed. A safe food handling knowledge test which includes more items for health information providers (HIPs) should be developed. Types of and places to conduct safe food handling training that are acceptable to HIPs need to be investigated. Furthermore, the impact of various educational interventions on safe food handling needs to be evaluated by scores from pre- and post-test data. 98 7 . 0 LPPIIDICBS Appendix 1. A project statement requesting Michigan local health departments to participate in the study 953 Appendix 1. A project statement requesting Michigan local health departments to participate in the study Michigan Association for Local Public Health 215 N. Walnut Street . Se tember 5‘ 1991 PO. Box 14065 Lansing. Ml 48901 “mus” p (517) 485-0660 Douglas A. Mad. MD President John PM" Vice-President David L. Ohmart , 14.0. John Mm” “a Health Officer Thflflflu. ‘ Allegan County Health Department Service Building, 2233 Thirty-Third Street Ldsaflwo Allegan, MI 49010 Samuuv Dear Dr.-0hmart: Your assistance is requested with an MSU study. The study is intended to determine the knowledge of safe food handling of health information providers in Michigan. MSU researchers are interested in the food handling knowledge of health infbrmation providers and how this knowledge may affect the public, specifically. families with young children. Targeted professionals to be included in this study are health educators, nurses, physicians, and sanitarians. The study would benefit especially from the input of sanitarians whose work concentration is foodservice. One possible outcome of this study is the creation of recommendations for curriculum revision in allied health professions. This MSU safe food handling project has received the assistance and endorsement of your state association, the Michigan Association for Local Public Health. Would you allow the health educators, nurses. physicians and sanitarians working in your local health department to participate in this study? Participation in the MSU safe food handling study involves completing a questionnaire on food handling. A copy of the questionnaire is enclosed for your review. The pretest for the project indicated that the questionnaire required approximately 15 minutes for completion. Responses are confidential: respondent names are not requested on the questionnaire; completed questionnaires'will be identified only by county. If you have questions regarding this study at any time. contact Carol Sawyer at MSU (517/353-9663) or Anita Turner. R.N.. at the Ingham County health Department (517/887-4311). Anita Turner and her nursing staff piloted this questionnaire in Ingham County earlier this summer. Executive Director Facsimile Machine Mark J. Bauer ' (517) 485-6412 e s ' 1i)0 Please return the addressed, prepaid postcard before October 1, 1991 with your reply. The individual you designate as Contact Person will receive the appropriate number of the surveys. Thank you in advance for your support and assistance. Sincerely, Carol A. Sawyer, Ph.D., R.D.* Associate Professor Dept. Food Science a Human Nutrition 517/353-9663 June Youatt, Ph.D. Associate Professor Dept. of Family and Child Ecology *Contact person Enclosures: reply postcard questionnaire Sandra Andrews. Ph.D., R.D. Assistant Professor Dept. Food Science & Human Nutrition Mark J. Bertler Executive Director Hich. Assoc. for Local Public Health ' 9.0. Box 14065 Lansing, HI '48901 517/485-0660 Appendix 2. A reply card for Michigan local health department use 101 Appendix 2. A reply card for Michigan local health department OLS’SMl ‘use Michigan State University Carol Sawyer, Ph. D. Department of Food Science and Human Nutrition East Lansing, Michigan 48824 Contact Person Title Local Health Department Address Phone Number ( ‘ 1 - Please Check All That Apply: Our health educators are willing. to assist. ' Send copies of the questionnaires. Our nurses are willing to assist. Send copies of the questionnaires. Our physicians are willing to assist. Send copies of the questionnaires. . . Our sanitarians are willing to assist. Send copies of the questionnaires. Our local health department is unable to assist you. Thank you. Please return this card no later than October-1, 1991. Appendix 3. A cover letter for each participating local health department 102 Appendix 3. A cover letter for each participating local health department MICHIGAN S'l'A'l'li UNlVIiRSITY DirAItl'MLVT or :00!) 50mm. as» HUMAN Nioi‘unmx IAN} IASSING 0 NICIHGAN ° Quid-I128 September 20, 1991 Bowwie Willings Health Ed. Grand-Traverse-Leelanau-Beniz District Health Department P.O. box 905 Traverse City, MI 49684-0905 Dear Ms Willings : This packet contains questionnaires from the Michigan State University Food Handling Study. These were requested by Mr. Gordon Rady, the Health Officer of your local health department. The purpose of this Study is to determine attitude and knowledge of food handling of health information providers. The return sheet attached to this cover letter indicates the number of questionnaires enclosed. Please check the contents of your packet against the return sheet to make sure you have received all of the materials your local health department requested. If not enough questionnaires were provided, please feel free to duplicate additional questionnaires. Please return the completed questionnaires to MSU by November 15 , 1991 using the enclosed, self-addressed, stamped envelope. It you have any questions about the contents of your packet, or about the procedure for distributing and collecting questionnaires , please call Carol Sawyer at (517)353-9663. The return address for all questionnaires is: Carol Sawyer Department of Food Science and Human Nutrition 139 Food Science Building Michigan State University East Lansing, MI 48824-1224 Thank you .very much for your assistance. sincerely, Carol A. Sawyer, Ph.D.. R.D. Associate Professor Enclosure; questionnaires return sheet self-addressed stamped envelope amm-an-duau—Mpqum—nhuha- Appendix 4. A return sheet for each participating local health department Appendix 4. A return sheet for each participating local health .103 department MSU FOOD HANDLING STUDY to improve the health of our Michigan children REHTHUQSHWIH‘ DIRE ONS : Complete and return this sheet with your questionnaires. ‘1. Fill in information for the contact person who distributed and collected the questionnaires. 2. Write in the table below the quantity of questionnaires returned. CONTACT PERSON TITLE LOCAL HEABTH DEPARTMENT ADDRESS ZIP CODE COUNT! DATE RETURNED PKONE mm (DAY) 1 1 — QUANTITY OF NUMBERS ON THE - ooss'rxouuunss ooss'rromnss‘ TYPE . SENT TO LOCAL . HEAEIH_DEEBBIHENI SENT RETURNED BEGIN END 1. Health Educator HE an Questionnaire (H8) 2. Nurse Questionnaire(HN) HE an 3. Physician - H2 fig Questionnaire (NP) . 4. Sanitarian as as *HE-Health Educator Questionnaire un-Nurse Questionnaire HP-Physician Questionnaire Questionnaire (HS) Hs-Sanitarian Questionnaire Please return all available questionnaires by novenber-ls, 1991. The return address for all questionnaires is: Carol Sawyer Department of Food Science and Human Nutrition 139 Food Science Building Michigan State University ' East Lansing, NI 48824-1224 THANK YOU Response frequencies of affiliated with health departments 104 Appendix 5. Response frequencies of health information providers (n=611) affiliated with local health departments MICHIGAN STATE UNIVERSITY FOOD HANDLING grow to improve the health of our Michigan children QUESTIONS FOR HEALTH H‘IFORMATION PROVIDERS Dear Health Information Provider: This study is designed to learn about your beliefs knowled e and practices. related to food handling. Food handling. refers go the things typically done when ,storing, preparing, cooking, and] or serv1ng food. Intonation learned from this stud will be used to educate Michigan children about .safe food handlirTg. Please note: ‘ 1. The questionnaire ‘will take about fifteen minutes to complete. 2 . Answers are confidential. 3. Your name is 1393 required. You indicate your voluntary agreement to participate com letin and returning this questionnaire. You may decline to lgynswerpany 0% the questions. ' Thank you in advance for your participation. Department of Food Science and Human Nutrition Michigan State University ‘East Lansing, HI 48824 517/353-9663 1. 3. 105 (Nflllfllldflfl! I!!! IIUUHIIIlflfllaflflflfllllfll‘PIKIVIIHHIB You do many important things to keep yourself healthy. Compared to most of the things you do to maintain your health, how important is sawing? (Check one) Safe food handling is the most important thing I do. Safe food handling is as important as most things I do. Safe food handling is less important than most things I do. Safe food handling is not important. I am not familiar with methods of safe food handling. EE ESE During the past year, from what ggngggg have you received information on food handling? (Check all that apply) Cooperative Extension Service (CBS) Family and friends Government pamphlets Local school district Newspapers, consumer magazines National/Nichigan Dairy Council Professional journals Professional or job related meeting Other- Pleue specify: W W V I have not received information on food handling. (Go to question 5) EEEEEEEEEE Of the choices you checked in question number 2 above, please circle the source of information that you believe provides the most ggggggtg information on safe food handling. (Circle one choice in question 2 above). Describe the most important formal ggginigg in safe food handling that you received during the past 12 months (April 1, 1990 to March 31, 1991). (Check A or 8 below and fill in the blank lines below if required) 29‘2; A. Topic/Name of Training Session Length Location Presenter (Sponsoring agency) Date figygg B. I have not received any formal training. 106 5. Please indicate below any intgggggign related to food handling you may have had with children in your professional area e EEEEEEEEEE (Check all that apply) Request that your co-workers talk to children and/or their parents. Talk to a child about food handling during office visits. Talk to groups of children about food handling in community settings. Talk to parents (guardians) during office visits for their child. Talk to educational personnel such as third grade teachers. Prepare written materials on safe food handling. other- Please specify: MW MW I do not see children professionally. No interaction with children on safe food handling. I would like an opportunity to work in this area. 6. Would you be willing to provide us with a copy of any on safe food handling (or tell us how to new obtain a copy) that you have used with children? 2.5} Yes 16‘}; No materials available. If yes, please write the necessary information on how to obtain the material here: Price 3 To keep fresh, raw ground beef safe to eat, the best place to 559;; it overnight is (Check one) EEEEE in a cupboard. in a kitchen sink. in a refrigerator. on the top of a kitchen counter. all of these choices are OK. 107 8. The best place to safely lhl! frozen, raw ground beef is (Check one) EEEEE in a cupboard. in a kitchen sink (without water). in a refrigerator. on the top of a kitchen counter. all of these choices are OK. 9. On which of the following foods are bacteria able to grow? (Check all that apply) EEEEEE baked potato broiled chicken breast corn oil glass of skim milk refried beans white vinegar 10. Which of the following activities is the best way to getting EEEE E sick from bacteria and viruses in food? (Check one) rinsing hands under very hot water before handling raw chicken washing hands with soap and clean water before handling raw chicken wiping hands on a clean towel before handling raw chicken none of these are important 11. A unopened carton of milk is stored in a refrigerator overnight. The highg;§_ggjg_§glpggltngg of the refrigerator would be (Check one and fill in the temperature if required) 5912! 11121 The temperature should be 55 °F (or 1.2 °C) I do not know the temperature. 12. Staphylococcus aureus, a potentially harmful bacteria, is most often introduced into potato salad from (Check one) EEEEE people who handle the potatoes. from diseased potatoes. soil and dust on the potatoes. all of these choices. none of these choices. 13. 14. 15. 16. 17. 18. 19. 20. 21. 108 You always can tell when a food such as ham has bacteria (germs) that could make you sick by how it looks, smells or tastes. (Check one) 2,2% true 29‘21 false When refrigerating leftover stew, which container will best lbmit the growth of harmful bacteria ?(Check one) fifiygg a shallow container such as uncovered cake pan (2 inches deep) 3,}; a deep container such as an uncovered eight-quart soup pct (12 inches deep) 38‘83 the depth of container is not important Professional title (e.g. H.D., D.C., R.D., L.P.N., physician, dentist, nurse practitioner) . S . t Medical practice specialty area (e.g. pediatrics, family medicine) W113?! How many years have you been in this specialty area? gyfigfiég yrs. What is your gender (sex)? 11‘81 female (zgyfig male What is your age? (Fill in blank) :2,§12,2 yrs. During a typical week, how many meals are made in your household? (Write in number of meals) 12,Zt§,§ meals per week are made in my household (number) Of the meals made in your household during a typical week, how many do you personally prepare? (Write in number of meals) I typically make 2‘Q;§&§ meals per week. (number) 109 22. For how many 99391991939 have your mother's ancestors been in the US? (Check one) newly immigrated (you were born outside of the US) one generation (your mother was born outside of the US) two generations (your mother's mother was born outside of the US) more than two generations I am not sure. BEE ELSE a visitor to the US (for example, a ex-change student) 23. The following question is 92919331. What is your main family hggggggggg? The reason for this question is that we would like to learn about the special food handling knowledge and practices of the various ethnic groups in Michigan. (Check all that apply) African-American (Black) Arab/Chaldean Asian/Pacific Islander 9,71 Asian Indian Chinese _Q._2_ 1,9; Filipino .913. Japanese EEE 9,23 Vietnamese 9,91 Korean Hispanic (Latino) 9,29 Central American 9,9! Mexican 9,28 Puerto Rican 9,95 South American E 9,91 Native Indian (American Indian) or Alaskan Native 99911 White, non-hispanic If none of the above adequately describes your ethnic heritage, please write it in here. 24. Please describe your g;11§gn§111_99§§igg. EEEEE farm town under 10,000 people or rural non-farm 110 town or city of 10,000 to 50,000 people suburb of city of over 50,000 people city of over 50,000 people or more (Check one) 25. What is the highggt professional and/or academic degree you have received (check as many as are applicable or highest degree IEEEEEE E EEEEEEEE obtained) 8.8. D.D.S. Dental hygienist Dentist 00°. L.P.N. M.D. M.S. P.A. Ph.D. R.D. R.N. EEEEEE Other professional degree. Please specify: 2,6} R.s. _9991 vecational less than $10,000 $20,001 $30,001 $40,001 $50,001 $60,001 $70,001 to to to to to to to $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 2,91 Associate Degree 26. The following question is gpgigggl. In what range is your annual household ingggg? (Check one) $100,001 $110,001 $120,001 $130,001 $140,001 $150,001 EEEEEEEE I do not wish to say or I do not know. $80,001 to $90,000 $90,001 to $100,000 to $110,000 to $120,000 to $130,000 to $140,000 to $150,000 or greater Please continue onto the next page. 111 we would like to hear from you. Please write any additional comments in the space provided below. rm YOU FOR YOUR PARTICIPATION IN THE N80 3001) HANDLING STUDY. Please return questionnaires to Carol A. Sawyer, Ph.D., R.D. Dept. of Food Science and Human Nutrition Michigan State University East Lansing, MI 48824 If you have any questions about this study, please call Dr. Sawyer at 517/353-9663. Appendix 6. Response frequencies of foodservice sanitarians (n=214) affiliated with local health departments 112 Appendix 6. Response frequencies of foodservice sanitarians 1. 3. (n=214) affiliated with local health departments (QUINNIIINNB INN! lflfiflhflllIEII‘flNIITIIHI‘PIKIVIDHIMB You do many important things to keep yourself healthy. Compared to most of the things you do to maintain your health, how important is We? (Check one) Safe food handling is the most important thing I do. Safe food handling is as important as most things I do. Safe food handling is less important than most things I do. Safe food handling is not important. I am not familiar with methods of safe food handling. EE EEE During the past year, from what ggggggg have you received information on food handling? (Check all that apply) Cooperative Extension Service (CBS) Pamily and friends Government pamphlets Local school district Newspapers, consumer magazines National/Michigan Dairy Council Professional journals Professional or job related meeting Others 9133'6 IP961fY8 ESA52_18!1_19h_§£31n1n§1_39931 WW I have not received information on food handling. (Go to question 5) E EEEEEEEEE Of the choices you checked in question number 2 above, please circle the source of information that you believe provides the most 199319;; information on safe food handling. (Circle one choice in question 2 above). Describe the most important formal ggjinigg in safe food handling that you received during the past 12 months (April 1, 1990 to March 31, 1991). (Check A or 8 below and fill in the blank lines below if required) 9191; A. I have received formal training. 99991 B. I have not received any formal training. 113 5. Please indicate below any 33391999123 related to food handling you may have had with children in your professional area. (Check all that apply) Request that your co-workers talk to children and/or their parents. Talk to a child about food handling during office visits. Talk to groups of children about food handling in community settings. Talk to parents (guardians) during office visits for their child. Talk to educational personnel such as third grade teachers. Prepare written materials on safe food handling. Other- Please Specify: Witness I do not see children professionally. No interaction with children on safe food handling. I would like an opportunity to work in this area. EEEEEEEEEE 6. Would you be willing to provide us with a copy of any gjfigggizg gggghigg_.;§gziglg on safe food handling (or tell us how to obtain a copy) that you have used with children? 1299; Yes 12991 No materials available. 7. To keep fresh, raw ground beef safe to eat, the best place to 199;; it overnight is (Check one) in a cupboard. in a kitchen sink. in a refrigerator. on the top of a kitchen counter. all of these choices are OK. EEEEE 8. The best place to safely 99;! frozen, raw ground beef is (Check in a cupboard. in a kitchen sink (without water). in a refrigerator. on the top of a kitchen counter. all of these choices are OK. EEEEEE 9. On which of the following foods are bacteria able to grow? (Check all that apply) baked potato broiled chicken breast corn oil glass of skim milk refried beans white vinegar EEEEEE 10. 11. 12. 13. 14. 15. 16. 17. 18. 114 Which of the following activities is the best way to getting sick from bacteria and viruses in food? (Check one) rinsing hands under very hot water before handling raw chicken washing hands with soap and clean water before handling raw chicken wiping hands on a clean towel before handling raw chicken Etéfi E none of these are important A unapened carton of milk is stored in a refrigerator overnight. The highggg_1gjg_tggpgrg§ggg of the refrigerator would be (Check one and fill in the temperature if required) 9999; The temperature should be 59 °P (or 1,2 °C) _9991 I do not know the temperature. Staphylococcus aureus, a potentially harmful bacteria, is most often introduced into potato salad from (Check one) people who handle the potatoes. from diseased potatoes. soil and dust on the potatoes. all of these choices. none of these choices. EEEEE You always can tell when a food such as ham has bacteria (germs) that could make you sick by how it looks, smells or tastes. (Check one) .5151 true 29,91 false When refrigerating leftover stew, which container will best lbmit the growth of harmful bacteria ?(Check one) 9191; a shallow container such as uncovered cake pan (2 inches deep) 1,51 a deep container such as an uncovered eight-quart soup pct (12 inches deep) 9,1; the depth of container is not important Professional title (e.g. H.D., D.C., R.D., L.P.N., physician, dentist, nurse practitioner) WW Medical practice specialty area (e.g. pediatrics, family medicine) Enh112_flssltb How many years have you been in this specialty area? 19999991 yrs. What is your gender (sex)? 2991; female 99921 male 19. 20. 21. 22. 23. 24. 115 What is your age? (Fill in blank) 37.112,g yrs. During a typical week, how many meals are made in your household? (Write in number of meals) 12999999 meals per week are made in my household (number) Of the meals made in your household during a typical week, how many do you personally prepare? (Write in number of meals) I typically make 9,915,; meals per week. (number) For how many gggggggiggg have your mother's ancestors been in the US? (Check one) newly immigrated (you were born outside of the US) one generation (your mother was born outside of the US) two generations (your mother's mother was born outside of the US) more than two generations I am not sure. EEE EEE a visitor to the US (for example, a ex-change student) The following question is 22519391. What is your main family ? The reason for this question is that we would like to learn about the special food handling knowledge and practices of the various ethnic groups in Michigan. (Check all that apply) African-American (Black) Arab/Chaldean Asian/Pacific Islander 9,21 Asian Indian E BEE Hispanic (Latino) _9991 Central American 9,01 Cuban _9921 Mexican _99§§ Puerto Rican 9,95 South American Native Indian (American Indian) or Alaskan Native White, non-hispanic tie-cribs your MW- (Check one) farm town under 10,000 people or rural non-farm town or city of 10,000 to 50,000 people suburb of city of over 50,000 people city of over 50,000 people or more EEEEEEEE 116 25. What is the highggg professional and/or academic degree you have received (check as many as are applicable or highest degree obtained) 2,93 Associate Degree 2.9.41 14.5. _§;Q§ R.S. 26. The following question is 92519931. In what range is your annual household 1999.1? E EEEEEEEE less than $10,000 $20,001 $30,001 $40,001 $50,001 $60,001 $70,001 to to to to to to to $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 my 3.5. 9.5! Ph.D. (Check one) EEEEEEEE $80,001 to $90,000 $90,001 to $100,000 $100,001 $110,001 $120,001 $130,001 $140,001 $150,001 I do not wish to say or I do not know. to $110,000 to $120,000 to $130,000 to $140,000 to $150,000 or greater Appendix 7. Response frequencies of health educators (n=52) affiliated with local health departments 117 Appendix 7. Response frequencies of health educators (n=52) 1. 3. affiliated with local health departments {NHIBTUINNB INN! IUUUMIIIJJUHURIUHEEUIIIHNJVIINHMB You do many important things to keep yourself healthy. Compared to most of the things you do to maintain your health, how important is aafs_fesd_handliss? (Check one) Safe food handling is the most important thing I do. Safe food handling is as important as most things I do. Safe food handling is less important than most things I do. Safe food handling is not important. I am not familiar with methods of safe food handling. BE EEE During the past year, from what ggggggg have you received information on food handling? (Check all that apply) Cooperative Extension Service (CBS) 0. Family and friends Government pamphlets Local school district Newspapers, consumer magazines National/Michigan Dairy Council Professional journals Professional or job related meeting other- Please apocify: State_lasi_noeksi_IY I have not received information.on food handling. (Go to question 5) EEEEEEEEEE Of the choices you checked in question number 2 above, please circle the source of information that you believe provides the most gggggggg information on safe food handling. (Circle one choice in question 2 above). Describe the most important formal tzgining in safe food handling that you received during the past 12 months (April 1, 1990 to March 31, 1991). (Check A or 8 below and fill in the blank lines below if required) _9991 A. I have received formal training. 99991 B. I have not received any formal training. 118 5. Please indicate below any 13992999193 related to food handling you may have had with children in your professional area e EEEEEEEEEE (Check all that apply) Request that your co-workers talk to children and/or their parents. Talk to a child about food handling during office visits. Talk to groups of children about food handling in community settings. Talk to parents (guardians) during office visits for their child. Talk to educational personnel such as third grade teachers. Prepare written materials on safe food handling. Other. Please specify: flgal§n_ggrglggy_§ggg I do not see children professionally. No interaction with children on safe food handling. I would like an opportunity to work in this area. 6. Would you be willing to provide us with a copy of any 919995111 on safe food handling (or tell us how to We obtain a copy) that you have used with children? 1199; Yes 29,91 No materials available. 7. To keep fresh, raw ground beef safe to eat, the best place to 139;; it overnight is (Check one) EEEEE 8? go EEEEE in a cupboard. in a kitchen sink. in a refrigerator. on the top of a kitchen counter. all of these choices are OK. best place to safely $91! frozen, raw ground beef is (Check in a cupboard. in a kitchen sink (without water). in a refrigerator. on the top of a kitchen counter. all of these choices are OK. 9. On which of the following foods are bacteria able to grow? (Check all that apply) EEEEEE baked potato broiled chicken breast corn oil glass of skim milk refried beans white vinegar 10. 11. 12. 13. 14. 15. 16. 17. 18. 119 Which of the following activities is the best way to getting sick from bacteria and viruses in food? (Check one) rinsing hands under very hot water before handling raw chicken washing hands with soap and clean water before handling raw chicken wiping hands on a clean towel before handling raw chicken none of these are important EESE E A unopened carton of milk is stored in a refrigerator overnight. The highggt_9919_tglpggggggg of the refrigerator would be (Check one and fill in the temperature if required) 9199; The temperature should be 55 °F (or 7,2 °C) 5999; I do not know the temperature. Staphylococcus aureus, a potentially harmful bacteria, is most often introduced into potato salad from (Check one) people who handle the potatoes. from diseased potatoes. soil and dust on the potatoes. all of these choices. EEEEE none of these choices. You always can tell when a food such as ham has bacteria (germs) that could make you sick by how it looks, smells or tastes. (Check one) .5181 true 9991; false When refrigerating leftover stew, which container will best limit the growth of harmful bacteria ?(Check one) 99991 a shallow container such as uncovered cake pan (2 inches deep) 1,73 a deep container such as an uncovered eight-quart soup pct (12 inches deep) 91991, the depth of container is not important Professional title (e.g. H.D., D.O., R.D., L.P.N., physician, dentist, nurse practitioner) Health_ssnsaters Medical practice specialty area (e.g. pediatrics, family medicine) Publis_fisalth How many years have you been in this specialty area? 9999999 yrs. What is your gender (sex)? 95921 female _§991 male 19. 20. 21. 22. 23. 24. 25. 26. 120 What is your age? (Fill in blank) 94,918,9 yrs. During a typical week, how many meals are made in your household? (Write in number of meals) 12,gt§,§ meals per week are made in my household (number) Of the meals made in your household during a typical week, how many do you personally prepare? (Write in number of meals) I typically make 9,119.9 meals per week. (number) For how many 99999991999 have your mother's ancestors been in the US? (Check one) newly immigrated (you were born outside of the US) one generation (your mother was born outside of the US) two generations (your mother's mother was born outside of the US) more than two generations The following question is 99919991. What is your main family 9993999999? The reason for this question is that we would like to learn about the special food handling knowledge and practices of the various ethnic groups in Michigan. (Check all that apply) EEEE 1,91 African-American (Black) 1,95 Asian/Pacific Islander 1.9; Filipino 92991 White, non-hispanic Please describe your 19919999191_9999199. (Check one) farm town under 10,000 people or rural non-farm town or city of 10,000 to 50,000 people suburb of city of over 50,000 people EEEEE city of over 50,000 people or more What is the 919999; professional and/or academic degree you have received (check as many as are applicable or highest degree obtained) _§99§ Associate Degree 51,91 8.8. 92991 M.S. The following question is 99919991. In what range is your annual household 199999? (Check one) less than $10,000 $10,000 to $20,000 $20,001 to $30,000 $50,001 to $60,000 $60,001 to $70,000 $70,001 to $80,000 $30,001 to $40,000 $130,001 to $140,000 $40,001 to $50,000 $140,001 to $150,000 I do not wish to say or I do not know. EEEEEE EEEEE Appendix 8. Response frequencies of public health nurses (n=260) affiliated with local health departments 121. Appendix 8. Response frequencies of public health nurses 1. 3. (n=260) affiliated with local health departments (DUIHEIIIMEB INN! lflfllfiflfll IJHIONDENIIIHI IIMTVIIHHIB You do many important things to keep yourself healthy. Compared to most of the things you do to maintain your health, how important is gafe_129§_haa§lias? (Check one) Safe food handling is the most important thing I do. Safe food handling is as important as most things I do. Safe food handling is less important than most things I do. Safe food handling is not important. I am not familiar with methods of safe food handling. EE EEE During the past year, from what 9991999 have you received information on food handling? (Check all that apply) Cooperative Extension Service (CBS) Family and friends Government pamphlets Local school district Newspapers, consumer magazines National/Michigan Dairy Council Professional journals Professional or job related meeting Other- Please specify: nutritieni£:§1_xxi_na§ie Enxir2nmental_healtn_nenar§ment _ EEEEEEEEEE I have not received information on food handling. (Go to question 5) 0f the choices you checked in question number 2 above, please circle the source of information that you believe provides the most 99931939 information on safe food handling. (Circle one choice in question 2 above). Describe the most important formal gxgiging in safe food handling that you received during the past 12 months (April 1, 1990 to March 31, 1991). (Check A or 8 below and fill in the blank lines below if required) 1,2: A. I have received formal training. 91921 B. I have not received any formal training. 122 5. Please indicate below any i999£99§199 related to food handling you may have had with children in your professional area. (Check all that apply) Request that your co-workers talk to children and/or their parents. Talk to a child about food handling during office Talk to groups of children about food handling in community settings. Talk to parents (guardians) during office visits for their child. Talk to educational personnel such as third grade teachers. Prepare written materials on safe food handling. I .th- I do not see children professionally. No interaction with children on safe food handling. I would like an opportunity to work in this area. EEEEEEEEEE 6. Would you be willing to provide us with a copy of any 9gg99§199 99999399_99§9£1919 on safe food handling (or tell us how to obtain a copy) that you have used with children? 9.2} Yes 1995; No materials available. 7. To keep fresh, raw ground beef safe to eat, the best place to 99919 it overnight is (Check one) _Q993 in a cupboard. _Q911 in a kitchen sink. 22921 in a refrigerator. _Q9Q§ on the top of a kitchen counter. _Q901 all of these choices are OK. 8. The best place to safely 999! frozen, raw ground beef is (Check one) _Q9Q§ in a cupboard. 1.25 in a kitchen sink (without water). 2191; in a refrigerator. _Q9Q; on the top of a kitchen counter. _Q991 all of these choices are OK. 9. On which of the following foods are bacteria able to grow? (Check all that apply) baked potato broiled chicken breast corn oil glass of skim milk refried beans white vinegar EEEEEE Other- Plane Opacity: W '_ ._ , 0 . 1 Z '_ Z - ‘ '. '_ 10. 11. 12. 13. 14. 15. 16. 17. 18. 123 Which of the following activities is the best way to 9991995 getting sick from bacteria and viruses in food? (Check one) rinsing hands under very hot water before handling raw chicken washing hands with soap and clean water before handling raw chicken wiping hands on a clean towel before handling raw chicken none of these are important EEEE E A unopened carton of milk is stored in a refrigerator overnight. The 919999§_9919_§9.99;9§919 of the refrigerator would be (Check one and fill in the temperature if required) 3299; The temperature should be 55 °F (or 1,2 °C) 9991; I do not know the temperature. Staphylococcus aureus, a potentially harmful bacteria, is most often introduced into potato salad from (Check one) people who handle the potatoes. from diseased potatoes. soil and dust on the potatoes. all of these choices. EEEEE none of these choices. You always can tell when a food such as ham has bacteria (germs) that could make you sick by how it looks, smells or tastes. (Check one) lflifil true §§9§1_ false When refrigerating leftover stew, which container will best limit the growth of harmful bacteria ?(Check one) 219;; a shallow container such as uncovered cake pan (2 inches deep) _§9§1 a deep container such as an uncovered eight-quart soup pot (12 inches deep) 99921 the depth of container is not important Professional title (e.g. H.D., D.0., R.D., L.P.N., physician, dentist, nurse practitioner) BiEli_LiEiEii_£nb11£_heal§h_nnr§2§ Medical practice specialty area (e.g. pediatrics, family medicine) W How many years have you been in this specialty area? 2,;t7,2 yrs. What is your gender (sex)? 219;; female 1,51 male 19. 20. 21. 22. 23. 24'. 25. 124 What is your age? (Fill in blank) 51,712,Q yrs. During a typical week, how many meals are made in your household? (Write in number of meals) 12,81§,§ meals per week are made in my household (number) 0f the meals made in your household during a typical week, how many do you personally prepare? (Write in number of meals) I typically make 19915591 meals per week. (number) For how many 99995991999 have your mother's ancestors been in the US? (Check one) newly immigrated (you were born outside of the US) one generation (your mother was born outside of the US) two generations (your mother's mother was born outside of the US) more than two generations E5 EEE I am not sure. The following question is 99§i9391. What is your main family 9993999999? The reason for this question is that we would like to learn about the special food handling knowledge and practices of the various ethnic groups in Michigan. (Check all that apply) African-American (Black) Arab/Chaldean Asian/Pacific Islander _Q9§1 Chinese _Q9§§ Filipino _Q9j; Japanese Hispanic (Latino) _Q911 South American EEE E E White, non-hispanic Please describe your 59919999191_99;§199. (Check one) farm town under 10,000 people or rural non-farm town or city of 10,000 to 50,000 people suburb of city of over 50,000 people city of over 50,000 people or more EEEEE What is the highgg; professional and/or academic degree you have received (check as many as are applicable or highest degree obtained) 2,93 Vocational 3,11 Associate Degree 51.1; 8.8. 151.11 3.3. _m L.P.N. m 11.11. 125 26. The following question is 999L999}. In what range is your annual household £99999? E EEEEEEEE less than $10,000 $20,001 $30,001 $40,001 $50,001 $60,001 $70,001 to to to to to to to $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 (Check one) EEEEEEEE $80,001 to $90,000 $90,001 to $100,000 $100,001 ' $110,001 $120,001 $130,001 $140,001 $150,001 I do not wish to say or I do not know. to $110,000 to $120,000 to $130,000 to $140,000 to $150,000 or greater Appendix 9. Response frequencies of public health nutritionists (n=61) affiliated with local health departments (126 Appendix 9. Response frequencies of public health nutritionists 1. 3. (n=61) affiliated with local health departments «nmuurrxxnms I‘llillflumflliJDflIOIDflNIICfll?PIKMVIIHHIB You do many important things to keep yourself healthy. Compared to most of the things you do to maintain your health, how important is 1a12_f29§_haafilias? (Check one) Safe food handling is the most important thing I do. Safe food handling is as important as most things I do. Safe food handling is less important than most things I do. Safe food handling is not important. I am not familiar with methods of safe food handling. {EEE EEE the past year, from what 9999999 have you received information on food handling? (Check all that apply) 7 Cooperative Extension Service (CBS) Family and friends Government pamphlets Local school district Newspapers, consumer magazines National/Michigan Dairy Council Professional journals Professional or job related meeting Other- Please Specify: 9211292.222rsei_£9s_near§ I have not received information on food handling. (Go to question 5) EEEEEEEEEE 0f the choices you checked in question number 2 above, please circle the source of information that you believe provides the most 99991999 information on safe food handling. (Circle one choice in question 2 above). Describe the most important formal tggining in safe food handling that you received during the past 12 months (April 1, 1990 to March 31, 1991). (Check A or B below and fill in the blank lines below if required) . 9.9% A. I have received formal training. 9199; B. I have not received any formal training. 127 5. Please indicate below any 19991999199 related to food handling you may have had with children in your professional area. (Check all that apply) Request that your co-workers talk to children and/or their parents. Talk to a child about food handling during office visits. . Talk to groups of children about food handling in community settings. Talk to parents (guardians) during office visits for their child. Talk to educational personnel such as third grade teachers. Prepare written materials on safe food handling. Other- Please specify: W W; I do not see children professionally. No interaction with children on safe food handling. I would like an opportunity to work in this area. EEEEEEEEEE 6. Would you be willing to provide us with a copy of any 911999119 t r on safe food handling (or tell us how to obtain a copy) that you have used with children? 9.2} Yes 1991; No materials available. 7. To keep fresh, raw ground beef safe to eat, the best place to 99999 it overnight is (Check one) _Q991 in a cupboard. _Q991 in a kitchen sink. _1QQ§ in a refrigerator. _Q991 on the top of a kitchen counter. _Q991 all of these choices are OK. 8. The best place to safely 999! frozen, raw ground beef is (Check ézalgg in a cupboard. 1.91 in a kitchen sink (without water). 2991; in a refrigerator. _Q991 on the top of a kitchen counter. _Q991 all of these choices are OK. 9. On which of the following foods are bacteria able to grow? (Check all that apply) baked potato broiled chicken breast corn oil glass of skim milk refried beans EEEEEE white vinegar 128 10. Which of the following activities is the best way to 9991999 11. 12. 13. 14. 15. 16. 17. 18. getting sick from bacteria and viruses in food? (Check one) rinsing hands under very hot water before handling raw chicken washing hands with soap and clean water before handling raw chicken wiping hands on a clean towel before handling raw chicken none of these are important Etafi E A unopened carton of milk is stored in a refrigerator overnight. The high99§_99£9_§9999;9§919 of the refrigerator would be (Check one and fill in the temperature if required) 79,53 The temperature should be 55 °F (or 7,2 °C) 2192; I do not know the temperature. Staphylococcus aureus, a potentially harmful bacteria, is most often introduced into potato salad from (Check one) people who handle the potatoes. from diseased potatoes. soil and dust on the potatoes. all of these choices. none of these choices. EEEEE You always can tell when a food such as ham has bacteria (germs) that could make you sick by how it looks, smells or tastes. (Check one) When refrigerating leftover stew, which container will best limit the growth of harmful bacteria ?(Check one) 15,51 a shallow container such as uncovered cake pan (2 inches deep) _§9§1 a deep container such as an uncovered eight-quart soup pot (12 inches deep) 19951_ the depth of container is not important Professional title (e.g. H.D., D.C., R.D., L.P.N., physician, dentist, nurse practitioner) BiDii_En££ilignL££§ Medical practice specialty area (e.g. pediatrics, family medicine) £3h11£_fl§slth How many years have you been in this specialty area? 2919999 yrs. What is your gender (sex)? _1991 female _Q993 male 19. 20. 21. 22. 23. 24. 25. 129 What is your age? (Fill in blank) 929991199 yrs. During a typical week, how many meals are made in your household? (Write in number of meals) 19,119,; meals per week are made in my household (number) 0f the meals made in your household during a typical week, how many do you personally prepare? (Write in number of meals) I typically make 11999999 meals per week. (number) For how many 99999991999 have your mother's ancestors been in the US? (Check one) newly immigrated (you were born outside of the US) one generation (your mother was born outside of the US) two generations (your mother's mother was born outside of the US) more than two generations I am not sure. a visitor to the US (for example, a ex-change student) The following question is 99919991. What is your main family 9999999999? The reason for this question is that we would like to learn about the special food handling knowledge and practices of the various ethnic groups in Michigan. (Check all that apply) EEE EEE 12919_ African-American (Black) 9,29 Asian/Pacific Islander 1,99 Vietnamese _1999 Korean 1,99 Bispanic (Latino) _1999 Mexican 12919 White, non-hispanic Please describe your 99919999191_9999199. (Check one) ALE! farm 19999 town under 10,000 people or rural non-farm 19999 town or city of 10,000 to 50,000 people 21999 suburb of city of over 50,000 people 9299; city of over 50,000 people or more What is the 9199999 professional and/or academic degree you have received (check as many as are applicable or highest degree obtained) 59,91 n.s. 29,31 ms. 4,59 911.1). 59,911 R.D. 130 26. The following question is 99919991. In what range annual household 199999? (Check one) E EEEEE less than $10,000 19919 $40,001 $10,000 to $20,000 9,29 $50,001 $20,001 to $30,000 2,99 $60,001 $30,001 to $40,000 9,99 $80,001 $70,001 to $80,000 I do not wish to say or I do not know. to to to to is your $50,000 $60,000 $70,000 $90,000 Appendix 10. Response frequencies of public health physicians (n=24) affiliated with local health departments 131 Appendix 10. Response frequencies of public health physicians 1. 3. (n=24) affiliated with local health departments «nounrrxcnms IKNR lflfilfiflfll IIHHGIIUHIICHI‘PIKMIIDEINB You do many important things to keep yourself healthy. Compared to most of the things you do to maintain your health, how important is 9999_9999_99991199? (Check one) Safe food handling is the most important thing I do. Safe food handling is as important as most things I do. Safe food handling is less important than most things I do. Safe food handling is not important. I am not familiar with methods of safe food handling. EEE EEE the past year, from what 9999999 have you received information on food handling? (Check all that apply) Cooperative Extension Service (CES) Family and friends Government pamphlets Local school district Newspapers, consumer magazines National/Michigan Dairy Council Professional journals Professional or job related meeting Other. Please specify: 1919919199 I have not received information on food handling. (Go to question 5) EEEEEEEEEE 0f the choices you checked in question number 2 above, please circle the source of information that you believe provides the most 99999999 information on safe food handling. (Circle one choice in question 2 above). Describe the most important formal 99919199 in safe food handling that you received during the past 12 months (April 1, 1990 to March 31, 1991). (Check A or 3 below and fill in the blank lines below if required) 9,29 A. I have received formal training. 79,99 8. I have not received any formal training. 132 5. Please indicate below any 19999999199 related to food handling you may have had with children in your professional area e EEEEEEEEEE (Check all that apply) Request that your co-workers talk to children and/or their parents. Talk to a child about food handling during office visits. ~ Talk to groups of children about food handling in community settings. Talk to parents (guardians) during office visits for their child. Talk to educational personnel such as third grade teachers. Prepare written materials on safe food handling. Other. Please specify: I do not see children professionally. No interaction with children on safe food handling. I would like an opportunity to work in this area. 6. Would you be willing to provide us with a copy of any 999999199 on safe food handling (or tell us how to we obtain a copy) that you have used with children? 19919 Yes 19999 No materials available. 7. To keep fresh, raw ground beef safe to eat, the best place to 99999 it overnight is (Check one) EEEEE in a cupboard. in a kitchen sink. in a refrigerator. on the top of a kitchen counter. all of these choices are OK. 8. The best place to safely 9999 frozen, raw ground beef is (Check EEEEEE in a cupboard. in a kitchen sink (without water). in a refrigerator. on the top of a kitchen counter. all of these choices are OK. 9. On which of the following foods are bacteria able to grow? (Check all that apply) EEEEEE baked potato broiled chicken breast corn oil glass of skim milk refried beans white vinegar 10. 11. 12. 13. 14. 15. 16. 17. 18. 133 Which of the following activities is the best way to 9999999 getting sick from bacteria and viruses in food? (Check one) rinsing hands under very hot water before handling raw chicken washing hands with soap and clean water before handling raw chicken wiping hands on a clean towel before handling raw chicken none of these are important E|§E E A unopened carton of milk is stored in a refrigerator overnight. The 9199999_9999_99999999999 of the refrigerator would be (Check one and fill in the temperature if required) 99999, The temperature should be 99 °F (or 7,2 °C) 91,99 I do not know the temperature. Staphylococcus aureus, a potentially harmful bacteria, is most often introduced into potato salad from (Check one) people who handle the potatoes. from diseased potatoes. soil and dust on the potatoes. all of these choices. EEEEE none of these choices. You always can tell when a food such as ham has bacteria (germs) that could make you sick by how it looks, smells or tastes. (Check one) 19919 true 99999 false When refrigerating leftover stew, which container will best limit the growth of harmful bacteria ?(Check one) 91.29 a shallow container such as uncovered cake pan (2 inches deep) 9,29 a deep container such as an uncovered eight-quart soup pot (12 inches deep) 99929 the depth of container is not important Professional title (e.g. M.D., D.O., R.D., L.P.N., physician, dentist, nurse practitioner) H1211_2191 Medical practice specialty area (e.g. pediatrics, family medicine) 232112.32alth How many years have you been in this specialty area? 199991199 yrs. What is your gender (sex)? 99.29 female 99999 male 19. 20. 21. 22. 23. 24. 25. 134 What is your age? (Fill in blank) 999991199 yrs. During a typical week, how many meals are made in your household? (Write in number of meals) 12,919.2 meals per week are made in my household (number) Of the meals made in your household during a typical week, how many do you personally prepare? (Write in number of meals) I typically make 1,9t§,9 meals per week. (number) For how many 99999991999 have your mother's ancestors been in the US? (Check one) 22929 newly immigrated (you were born outside of the US) 19919 one generation (your mother was born outside of the US) 12999 two generations (your mother's mother was born outside of the US) 91999 more than two generations 9,29 I am not sure. The following question is 99919991. What is your main family 9999999999? The reason for this question is that we would like to learn about the special food handling knowledge and practices of the various ethnic groups in Michigan. (Check all that apply) _9999 African-American (Black) 99999 Asian/Pacific Islander 9,99 Asian Indian 29999 Filipino 9,29 Korean 9.29 Hispanic (Latino) 9,29 Central American 99929 White, non-hispanic Please describe your 99919999191_9999199. (Check one) 9,29 farm 29999 town under 10,000 people or rural non-farm 13999, town or city of 10,000 to 50,000 people 29999 suburb of city of over 50,000 people 99999 city of over 50,000 people or more What is the 9199999 professional and/or academic degree you have received (check as many as are applicable or highest degree obtained) 39,99 8.8. 12959 13.0. 29929 M.S. 99999 H.D. 135 26. The following question is 99919991. In what range is your annual household 199999? (Check one) $50,001 to $60,000 9,29 $100,001 to $110,000 $60,001 to $70,000 9,29 $120,001 to $130,000 $70,001 to $80,000 _§9;9 $150,001 or greater $90,001 to $100,000 ’ E EEEE I do not wish to say or I do not know. Appendix 11. A cover letter requesting Michigan family practice physicians to participate in the study 1:36 Appendix 11. A cover letter requesting Michigan family practice physicians to participate in the study MICHlCAN S'I‘A'l'li UNH’HRSI'I'Y __§_.____ D'l'AflrfliiNt 0| “)0" .VCIINCOI AN" Hl'flAN NU‘I‘IITIUN [.ASY IANMNG 0 NILIIIGAN 0 dlllddlj£ November 6, 1991 John Ockenfels 924 Swinton Sault St. Marie, MI 49783 Dear Dr. Ockenfels: This MSU safe food handling project has re of your state associa ceived the assistance tion, the Michigan Academy of Family Practice Association. This packet contains two questionnaires, one for you and one for n's assistant in your office. Would you s to complete one of the questionnaires? At the same time, researchers would like to encourage the participation of your office nurse (R.W. or L.P.N.) or assistant (P.A.) by having the nurse or assistant complete one .of the enclosed questionnaires. Completed questionnaires may be mailed back to MSU in the enclosed self-addressed office before November 27, 1991. Responses are confidential; respondent names are not requested on the questionnaire; completed questionnaires will be identified only‘by county. If you have any questions regardin 9 this study at any time, please call Carol Sawyer at nsu (517/353-9663). Thank you very much in advance for your support and assistance. sincerely, W a. _w.,«./ Carol A. Sawyer, Ph.D., R.D. Associate Professor Enclosures: two questionnaires self-addressed envelope ”‘1 l a an .Vlafl-‘n'ov Adan-If“ ‘wtooa'ly leach-nae Appendix 12. Response frequencies of family practice physicians (n=129) 137 Appendix 12. Response frequencies of family practice physicians (n=129) {malunrxcnns It”! lflfilfiflfll IlflflflllflMPICfll?PIM’VIIHHIB 1. You do many important things to keep yourself healthy. Compared to most of the things you do to maintain your health, how important 1' safs_£299_han§lins? (Check one) .2l1i QZJB: 2143: .JLQi .3all During Safe food handling is the most important thing I do. Safe food handling is as important as most things I do. Safe food handling is less important than most things I do. Safe food handling is not important. I am not familiar with methods of safe food handling. the past year, from what 9999999 have you received information on food handling? (Check all that apply) Cooperative Extension Service (CBS) Family and friends Government pamphlets Local school district National/Michigan Dairy Council Professional journals Professional or job related meeting Other. Please specify: 3919919199 llduei;bflll Wm,” , 3,... M.,... (7,9,. mm... m“... llgfirinéli 13;11_L£L§11 .JL11_LJu§1l iflafliJAldfii I have not received information on food handling. (Go to question 5) 3. Of the choices you checked in question number 2 above, please circle the source of information that you believe provides the most 99999999 information on safe food handling. (Circle one choice in question 2 above). Describe the most important formal 99919199 in safe food handling that you received during the past 12 months (April 1, 1990 to March 31, 1991). (Check A or 3 below and fill in the blank lines below if required) 1,99 A. I have received formal training. sfihll B. I have not received any formal training. 138 5. Please indicate below any 19999999199 related to food handling you may have had with children in your professional area e EEEEEEEEEE (Check all that apply) Request that your co-workers talk to children and/or their parents. Talk to a child about food handling during office visits. - Talk to groups of children about food handling in community settings. Talk to parents (guardians) during office visits for their child. Talk to educational personnel such as third grade teachers. Prepare written materials on safe food handling. other. Please specify: W W: te s I do not see children professionally. No interaction with children on safe food handling. I would like an opportunity to work in this area. 6. Would you be willing to provide us with a copy of any 919999199 on safe food handling (or tell us how to obtain a copy) that you have used with children? _Q9Q9 Yes 21999 No materials available. 7. To keep fresh, raw ground beef safe to eat, the best place to 99999 it overnight is (Check one) EEEEE 23’ O 8. T o a 3 EEEEE in a cupboard. in a kitchen sink. in a refrigerator. on the top of a kitchen counter. all of these choices are OK. best place to safely 9999 frozen, raw ground beef is (Check in a cupboard. in a kitchen sink (without water). in a refrigerator. on the top of a kitchen counter. all of these choices are OK. 9. On which of the following foods are bacteria able to grow? (Check EEEEEE all that apply) baked potato broiled chicken breast corn oil glass of skim milk refried beans white vinegar 10. 11. 12. 13. 14. 15. 16. 17. 18. 139 Which of the following activities is the best way to 9999999 getting sick from bacteria and viruses in food? (Check one) rinsing hands under very hot water before handling raw chicken washing hands with soap and clean water before handling raw chicken wiping hands on a clean towel before handling raw chicken EE:E E none of these are important A unopened carton of milk is stored in a refrigerator overnight. The 9199999_9919_99999999999 of the refrigerator would be (Check one and fill in the temperature if required) 91929 The temperature should be 95 °F (or 7,2 °C) 99999 I do not know the temperature. Staphylococcus aureus, a potentially harmful bacteria, is most often introduced into potato salad from (Check one) people who handle the potatoes. from diseased potatoes. soil and dust on the potatoes. all of these choices. none of these choices. EEEEE You always can tell when a food such as ham has bacteria (germs) that could make you sick by how it looks, smells or tastes. (Check one) 9,29 true 29999 false When refrigerating leftover stew, which container will best limit the growth of harmful bacteria ?(Check one) 29999 a shallow container such as uncovered cake pan (2 inches deep) 19,19 a deep container such as an uncovered eight-quart soup pot (12 inches deep) 99919 the depth of container is not important Professional title (e.g. M.D., D.O., R.D., L.P.N., physician, dentist, nurse practitioner) 51211.2191 Medical practice specialty area (e.g. pediatrics, family medicine) W How many years have you been in this specialty area? 129991992 yrs. What is your gender (sex)? 21929 female 19999 male 19. 20. 21. 22. 23. 24. 25. 140 What is your age? (Pill in blank) 929991999 yrs. During a typical week, how many meals are made in your household? (Write in number of meals) 19999592_meals per week are made in my household (number) Of the meals made in your household during a typical week, how many do you personally prepare? (Write in number of meals) I typically make 5,9:9,2 meals per week. (number) For how many 99999991999 have your mother's ancestors been in the US? (Check one) newly immigrated (you were born outside of the US) one generation (your mother was born outside of the US) two generations (your mother's mother was born outside of the US) more than two generations BE EEE I am not sure. The following question is 99919991. What is your main family 9999999999? The reason for this question is that we would like to learn about the special food handling knowledge and practices of the various ethnic groups in Michigan. (Check all that apply) African-American (Black) Asian/Pacific Islander 1,99 Asian Indian _Q999 Filipino Hispanic (Latino) _2999 South American E E EB White, non-hispanic Please describe your 99919999191_9999199. (Check one) farm town under 10,000 people or rural non-farm town or city of 10,000 to 50,000 people suburb of city of over 50,000 people city of over 50,000 people or more EEEEE What is the 9199999 professional and/or academic degree you have received (check as many as are applicable or highest degree obtained) 99,39 8.8. _;_,_19 14.3. _9_,_e9 911.0. 12959 0.0. 93939 5.0. 141 26. The following question is 99919991. In what range is your annual household 199999? E EEEEEEE $30,001 $40,001 $50,001 $60,001 $70,001 $80,001 $90,001 to to to to to to to $40,000 $50,000 $60,000 $70,000 $80,000 $90,001 (Check one) EEEEEE $100,000 $100,001 $110,001 ‘$120,00l $130,001 $140,001 $150,001 I do not wish to say or I do not know. to $110,000 $120,000 $130,000 $140,000 $150,000 greater ‘THJIE’WEIEMILWIEHMW