Promoting Food Safety Awareness for Older Adults by Using Online Education Modules

Introduction

Adults aged 65 and over are susceptible to and at greater risk for food-borne illness than other adults (Lund & O'Brien, 2011; Smith, 1998). Behravesh et al. (2011) reported that most deaths from food-borne illness (58%) occur in adults aged 65 and over. Similarly, the Centers for Disease Control and Prevention (CDC) reported that in 2012, adults aged 60 and over had consistently higher hospitalization and mortality rates than other age groups for all the major food pathogens tracked (Centers for Disease Control and Prevention, 2014).

Older adults may not be aware of their higher food safety risk (Cates et al., 2009; Gettings & Kiernan, 2001). Cates et al. (2009) found that 41% of older adult respondents to a survey of food safety knowledge and behaviors disagreed that they were at higher risk for food-borne disease due to age. In a study of food safety–related trends and perceptions, Fein, Lando, Levy, Teisl, and Noblet (2011) found that adults age 65 and over had a lower perception of food safety–related risk than adults aged 18–29. Additionally, the food preparation practices (e.g., cooking, handling, storage) of older adults may be placing them at risk of food-borne illness (Gettings & Kiernan, 2001). The lowered awareness of food-borne illness risk and unsafe food handling practices of older adults warrants the creation of Extension-delivered, theory-based food safety education programming, particularly because public health interventions have successfully targeted this population (Martin, Tamblyn, Ahmed, & Tannenbaum, 2013; McClelland, Jayaratne, & Bird, 2013; Wohlgenant, Godwin, Cates, & Stone, 2015).

Social Marketing Theory

One theory used in the development of public health interventions targeting behavior change is social marketing theory (SMT). In practice, SMT makes use of marketing strategies, tools, and theory to influence behavior change (Lee & Kotler, 2011; Neiger, Thackeray, Barnes, & McKenzie, 2003). Lefebvre and Rochlin (1997) identify the steps of SMT: planning, choosing content and delivery method(s), developing and testing tools, implementing, assessing, and revising. The planning step involves collecting information about the needs and preferences of the target population and using this information to customize both the content of the intervention and the method(s) of delivery (Kreuter, Strecher, & Glassman, 1999; Lee & Kotler, 2011; Parks & Moody, 1986). Francis, Martin, and Taylor (2011) found that tailoring an online nutrition education program to the target audience's needs and preferences led to perceptions of the program as appealing and relevant.

Online Education

Today's older adults are using technology, which offers educational opportunities. Online educational tools can increase self-efficacy (confidence to perform a certain behavior) and lead to behavior change (Campbell, Koszewski, Behrends, King, & Stanek-Krogstrand, 2009). Furthermore, online Extension-delivered programs have been shown to increase food safety knowledge and familiarity (Francis, 2014).

When developing education programs for older adults, online opportunities typically are not explored due to misperceptions about older adults' use of technology. Flynn, Smith, and Freese (2006) reported that older adults actively seek health information online; in fact, Smith (2014) reported a recent increase, from 53% to 59%, in Internet usage by adults aged 65 and older. Additionally, older adults are willing to use technology-based food safety educational materials (Kosa, Cates, Godwin, Ball, & Harrison, 2011). These findings present a unique opportunity for Extension to provide older adults with online food safety education. The goal of the project discussed here was to develop and evaluate online SMT-based food safety education modules targeting the food safety education needs of older adults.

Methods

Needs Assessment

Older adults attending local congregate meal sites (n = 29) and residing in retirement communities (n = 58) completed a 10-question food safety quiz (University of Hawaii Cooperative Extension Service, 2006) to identify areas for food safety education. This quiz asked about the participants' frequency of completing certain food safety behaviors (Table 1). Quiz responses were tabulated using descriptive statistics. Those with higher frequencies of "No" or "Sometimes" responses (35% or higher) were identified as "areas of need," and subsequent food safety education modules were developed.

Development and Evaluation of Modules

The results from the needs assessment indicated a major knowledge gap related to safe thawing practices, with 64% of participants answering "No" or "Sometimes" to the relevant question (Table 1). In response, three 5- to 8-min online modules were developed, addressing temperature control of foods: "Thaw Safely!" (safe thawing practices), "It's All About the Temperature!" (thermometer use), and "Freeze Smart!" (freezing foods).

Table 1.
Needs Assessment Results

Food Safety Quiz Question	Number	Percentage (%)a
When grocery shopping, I pick up refrigerated and frozen foods just before checking out.b
Yes	55	63.2
No/Sometimes	31	35.6
No response	1	1.1
I check "sell-by" or "use-by" dates on packages when shopping or eating.
Yes	51	58.6
No/Sometimes	36	41.4
When I bring my groceries home, I refrigerate cold foods immediately.b
Yes	86	98.9
No/Sometimes	1	1.1
I wash my hands before I prepare food.
Yes	74	85.1
No/Sometimes	13	14.9
I keep raw meat or poultry juice away from other foods by using separate cutting boards.
Yes	60	69.0
No/Sometimes	27	31.0
I wash cutting boards that have touched raw meat or poultry between uses.
Yes	80	92.0
No/Sometimes	6	6.9
No response	1	1.1
I always thaw meat in the refrigerator.b
Yes	30	34.5
No/Sometimes	56	64.4
No response	1	1.1
I refrigerate my leftovers immediately.b
Yes	73	83.9
No/Sometimes	13	14.9
No response	1	1.1
Spoiled leftover food does not always smell, taste, or look bad, so when I'm in doubt, I throw it out.
Yes	74	85.1
No/Sometimes	12	13.8
No response	1	1.1
I keep kitchen towels and sponges clean.
Yes	74	85.1
No/Sometimes	11	12.6
No response	2	2.3
aPercentages do not always add up to 100 due to rounding. bTopic relates to food temperature.

Each mini-module highlights the key recommendations for temperature-related behaviors and will be posted on the older adult–focused Extension website, Mid Life and Beyond (http://www.extension.iastate.edu/humansciences/midlife-and-beyond). Each mini-module includes hyperlinks to additional online resources. The mini-modules were created using PowerPoint with voice-over recordings in Adobe Presenter (Francis, 2014; Francis et al., 2011).

Mini-module evaluations were conducted at one of the retirement communities that had participated in the needs assessment. Participants watched the online modules in a group setting and completed evaluation post-pre surveys. Survey results were entered in the online survey system Qualtrics, where they were analyzed using descriptive statistics.

Results

Demographics

Eighty-seven older adults (57 females, 27 males, 3 no response), aged 64 to 92 years (81.3 years average), completed the needs assessment. The online module evaluations were completed by residents at one of the needs assessment retirement communities, primarily females, aged 73 to 92 years (81.4 years average; Table 2).

Post-Pre Evaluation

All participants reported an increase in familiarity after viewing the modules for each of the topics addressed (Table 2). Additionally, the majority reported being "very likely" to apply the advice mentioned during the module (Table 2).

Table 2.
Participant Evaluation Post-Pre Survey

Post-Pre Survey Question	It's All About the Temperature! (n = 15)	Freeze Smart! (n = 15)	Thaw Safely! (n = 16)
Gender
Male	3	3	3
Female	12	12	13
Prefamiliarity with mini-module topic
Not familiar	0 (0.0%)	0 (0.0%)	0 (0.0%)
Somewhat familiar	9 (60.0%)	6 (40.0%)	11 (68.8%)
Very familiar	6 (40.0%)	9 (60.0%)	5 (31.2%)
Postfamiliarity with mini-module topic
Not familiar	0 (0.0%)	0 (0.0%)	1 (6.2%)
Somewhat familiar	3 (20.0%)	3 (20.0%)	4 (25.0%)
Very familiar	12 (80.0%)	12 (80.0%)	11 (68.8%)
Likelihood of applying some advice mentioned in the lesson
Not likely	1 (6.7%)	0 (0.0%)	0 (0.0%)
Somewhat likely	2 (13.3%)	3 (20.0%)	0 (0.0%)
Very likely	12 (80.0%)	12 (80.0%)	16 (100.0%)

Summary

The online food safety education mini-modules were well-received by participants and were effective in promoting awareness of recommended food safety practices for older adults. These findings support the development of additional online food safety education opportunities for older adults. On the basis of the needs assessment data collected, future topics might include food packaging dates and purchasing of refrigerated and frozen foods.

References

Behravesh, C. B., Jones, T. F., Vugia, D. J., Long, C., Marcus, R., Smith, K., . . . Henao, O. L. (2011). Deaths associated with bacterial pathogens transmitted commonly through food: Foodborne Diseases Active Surveillance Network (FoodNet), 1996–2005. Journal of Infectious Diseases, 204(2), 263–267.

Campbell, C., Koszewski, W., Behrends, D., King, J., & Stanek-Krogstrand, K. (2009). The effectiveness of distance education, using a blended method of delivery, for limited resource audiences in the nutrition education program. Journal of the American Dietetic Association, 109(9), A97.

Cates, S. C., Kosa, K. M., Karns, S., Godwin, S. L., Speller-Henderson, L., Harrison, R., & Ann Draughon, F. (2009). Food safety knowledge and practices among older adults: Identifying causes and solutions for risky behaviors. Journal of Nutrition for the Elderly, 28(2), 112–126.

Centers for Disease Control and Prevention (2014). Foodborne Diseases Active Surveillance Network: FoodNet surveillance report for 2012 (final report). Atlanta, GA.

Fein, S. B., Lando, A. M., Levy, A. S., Teisl, M. F., & Noblet, C. (2011). Trends in U.S. consumers' safe handling and consumption of food and their risk perceptions, 1988 through 2010. Journal of Food Protection, 74(9), 1513–1523.

Flynn, K. E., Smith, M. A., & Freese, J. (2006). When do older adults turn to the Internet for health information? Findings from the Wisconsin Longitudinal Study. Journal of General Internal Medicine, 21(12), 1295–1301.

Francis, S. L. (2014). Hybrid food preservation program improves food preservation and food safety knowledge. Journal of Extension [Online], 52(4) Article 4TOT8. Available at: http://www.joe.org/joe/2014august/tt8.php

Francis, S. L., Martin, P., & Taylor, K. (2011). Revising an Extension education website for limited resource audiences using social marketing theory. Journal of Extension [Online], 49(6) Article 6FEA7. Available at: http://www.joe.org/joe/2011december/a7.php

Gettings, M. A., & Kiernan, N. E. (2001). Practices and perceptions of food safety among seniors who prepare meals at home. Journal of Nutrition Education, 33(3), 148–154.

Kosa, K. M., Cates, S. C., Godwin, S. L., Ball, M., & Harrison, R. E. (2011). Effectiveness of educational interventions to improve food safety practices among older adults. Journal of Nutrition in Gerontology and Geriatrics, 30(4), 369–383.

Kreuter, M. W., Strecher, V. J., & Glassman, B. (1999). One size does not fit all: The case for tailoring print materials. Annals of Behavioral Medicine, 21(4), 276–283.

Lee, N. R., & Kotler, P. (2011). Social marketing: Influencing behaviors for good. Los Angeles, CA: Sage Publications.

Lefebvre, R. C., & Rochlin, L. (1997). Social marketing. In K. Glanz, F. M. Lewis, & B. K. Rimer (Eds.), Health behavior and health education: Theory, research, and practice (2nd ed., pp. 384–402). San Francisco, CA: Jossey-Bass.

Lund, B. M., & O'Brien, S. J. (2011). The occurrence and prevention of foodborne disease in vulnerable people. Foodborne Pathogens and Disease, 8(9), 961–973.

Martin, P., Tamblyn, R., Ahmed, S., & Tannenbaum, C. (2013). A drug education tool developed for older adults changes knowledge, beliefs and risk perceptions about inappropriate benzodiazepine prescriptions in the elderly. Patient Education and Counseling, 92(1), 81–87.

McClelland, J. W., Jayaratne, K. S. U., & Bird, C. L. (2013). Nutrition education brings behavior and knowledge change in limited-resource older adults. Journal of Extension [Online], 51(2) Article 2FEA1. Available at: http://www.joe.org/joe/2013april/a1.php

Neiger, B. L., Thackeray, R., Barnes, M. D., & McKenzie, J. F. (2003). Positioning social marketing as a planning process for health education. American Journal of Health Studies, 18(2/3), 75–81.

Parks, S. C., & Moody, D. L. (1986). A marketing model: Applications for dietetic professionals. Journal of the American Dietetic Association, 86(1), 37–40, 43.

Smith, A. (2014). Older adults and technology use. Retrieved May 18, 2015 from http://www.pewinternet.org/2014/04/03/older-adults-and-technology-use/

Smith, J. L. (1998). Foodborne illness in the elderly. Journal of Food Protection, 61(9), 1229–1239.

University of Hawaii Cooperative Extension Service (2006). Be safe: A home guide to help keep food safe. Retrieved May 18, 2015 from http://www.ctahr.hawaii.edu/oc/freepubs/pdf/FN-5.pdf

Wohlgenant, K. C., Godwin, S. L., Cates, S. C., & Stone, R. (2015). Working with individuals who provide nursing care to educate older adults about foodborne illness prevention: The Food Safety Because You Care! intervention. Journal of Biomedical Education.