February 2019 // Volume 57 // Number 1 // Research In Brief // v57-1rb11
Gaps in Safe Food Handling Practices of Older Adults
We identified gaps in safe food handling practices that may be placing older adults at increased risk of food-borne illness. A convenience sample of 1,019 older adults completed the Food Safety Behavior Questionnaire. Majority groups among participants were those who were female, those who were White, and those who were widowed. Participants had lower adherences to safe practices related to temperature control, attention to sell-by/use-by dates on food packages, and cross-contamination. Adherences were significantly (p < .05) influenced by gender, race/ethnicity, age, marital status, and education. Our findings suggest the need for older adult–focused safe food handling education related to temperature control, product selection practices, and cross-contamination.
Food safety education targeting specific safe food handling practice gaps experienced by older adults is needed. Older adults are at increased risk of food-borne illness due to chronic disease, effects of medical treatments, poor nutritional status, and age-related physiological function changes (U.S. Department of Agriculture & U.S. Food and Drug Administration [FDA], 2011). Each year, food-borne illness affects 48 million people nationally (U.S. FDA, 2017); among these cases, children and older adults are the most affected (U.S. FDA, 2017). It is important for older adults to understand food safety risk so that they can practice safe food handling behaviors.
Despite experiencing higher food safety risk, older adults may not be aware of their food safety risk (Cates et al., 2009; Gettings & Kiernan, 2001). Specifically, Cates et al. (2009) reported that 41% of older adults did not feel that they were at higher food safety risk. It also has been reported that older adults were less likely to be concerned or to change food-related practices after publicized food-borne outbreaks (SteelFisher, Blendon, Hero, & Ben‐Porath, 2013). Furthermore, those aged 65 and over may be cooking, handling, and storing food in ways that increase risk of food-borne illness (Gettings & Kiernan, 2001).
One strategy for promoting better understanding of and adherence to recommended safe food handling practices among older adults is to implement theory-based education. Theory-based nutrition and food safety education is recommended for establishing evidence-based health programming (Brownson, Baker, Leet, Gillespie, & True, 2011). One program development theory, social marketing theory (SMT), is related to ensuring that a program is designed to meet the needs and preferences of the target audience (Lefebvre & Rochlin, 1997).
Application of SMT includes involving the target audience throughout the development process and has been demonstrated to be effective in producing measurable behavior change (Francis & Taylor, 2009; Francis, Taylor, & Haldeman, 2009; Lefebvre & Rochlin, 1997; Roy, Francis, Shaw, & Rajagopal, 2016; Snow & Benedict, 2003). SMT emphasizes using research and test audiences to tailor programs to the specific needs and preferences of the larger target audience (Francis, Martin, & Taylor, 2011; Lefebvre & Rochlin, 1997; Roy et al., 2016; Snow & Benedict, 2003). Applying SMT is a cyclic process comprising six steps, with each step being essential to producing a client-centered curriculum that results in measurable outcomes. The six steps are
- planning and strategizing,
- selecting channels and materials,
- developing materials and pretesting,
- implementing the program,
- assessing effectiveness, and
- using feedback to revise the program (Lefebvre & Rochlin, 1997).
In the study we describe herein, we focused on SMT step 1. Our goal was to identify gaps in safe food handling practices among older adults participating in Supplemental Nutrition Assistance Program Education (SNAP-Ed) in a midwestern state. As part of program planning and strategizing (SMT step 1), needs assessments are helpful for identifying target audience needs and/or preferences related to a specific program and/or intervention. Our long-term goal was to develop older adult–focused food safety education materials and messages based on identified needs and preferences.
Participants and Recruitment
A convenience sample of 1,019 older adults was recruited from 81 randomly selected congregate meal sites across 58 counties (44 rural, 14 urban) in a Midwest state. These older adults were participating in a larger, statewide SNAP-Ed evaluation study. Rural counties were defined as those aligning with Rural-Urban Continuum Code values of 4 ("non-metro") or higher (U.S. Department of Agriculture Economic Research Service, 2013).
Participant recruitment was accomplished through in-person presentations conducted at the meal sites. The study protocol was reviewed and approved for exempt status by Iowa State University's institutional review board.
We assessed safe food handling practices using the 10-question Food Safety Behavior Questionnaire, which measures the frequencies of specific food handling behaviors (University of Hawaii Cooperative Extension Service, 2006). We selected this questionnaire because it addresses three core principles of the Fight BAC! food safety campaign (i.e., chill, clean, and separate) (Partnership for Food Safety Education, n.d.) as well as food preparation, selection, and leftovers topics. The questionnaire was evaluated for face and content validity by the research team.
Participants responded by choosing "Yes," "Sometimes," or "No" to describe the frequency of implementing specific safe food handling behaviors in their homes. We calculated individual summated scores; maximum total score was 10 points, with a higher score indicating greater frequency of implementing a food safety behavior.
Participants also answered sociodemographic questions about gender, racial/ethnic group, age, marital status, and education. Participants completed both the Food Safety Behavior Questionnaire and the sociodemographic questionnaire at baseline, before any intervention occurred.
We conducted statistical analyses using IBM SPSS Statistics, version 24.0. We used descriptive statistics to assess the response frequency for each question and conducted chi-square tests to determine whether differences in safe food handling practices existed relative to the sociodemographic variables of gender, racial/ethnic group, age, marital status, and education. For the chi-square analyses, we compared response frequencies with expected frequencies. We identified statistical significance as p < .05
For data analytic purposes, we collapsed questionnaire responses into two categories, "Yes" and "No/Sometimes." Additionally, we collapsed the applicable characteristics for some sociodemographic variables into two categories. Race/ethnicity responses were organized to identify two groups: persons of color (i.e., African Americans, Asians, or Hispanics/Latinos/Latinas) and Whites. Marital status was dichotomized as "married" and "nonmarried" (i.e., divorced, single, or widowed). Education was recoded as "high school or less" (i.e., high school degree/GED or less) and "some college and above."
Participants were mostly female (76.3%), White (95.8%), and widowed (52.8%), and many (68%) had a high school/GED education or higher (Table 1).
|Marital status (1,013)|
|Associate's degree/technical degree||77||7.7|
|Bachelor's degree or higher||144||14.3|
|High school or GED||463||46.0|
|Less than high school||93||9.2|
|aNumber in parentheses is number of respondents for questionnaire item.|
Top Safe Food Handling Practice Gaps
The top four safe food handling practices to which participants responded "No" or "Sometimes" were
- "thaw meat in the refrigerator" (50.0%);
- "pick up refrigerated and frozen foods just before checking out" (40.3%);
- "check 'sell-by' or 'use-by' dates on packages when shopping or eating" (34.1%); and
- "keep raw meat or poultry juice away from other foods by using separate cutting boards" (21.5%) (Table 2).
|Safe food handling practicea||Number||Percentage|
|I always thaw meat in the refrigerator. (988)|
|When grocery shopping, I pick up refrigerated and frozen foods just before checking out. (988)|
|I check "sell-by" or "use-by" dates on packages when shopping or eating. (986)|
|I keep raw meat or poultry juice away from other foods by using separate cutting boards. (974)|
|I refrigerate my leftovers immediately. (969)|
|I wash my hands before I prepare food. (985)|
|I keep kitchen towels and sponges clean. (981)|
|Spoiled leftover food does not always smell, taste, or look bad, so when I'm in doubt, I throw it out. (992)|
|I wash cutting boards that have touched raw meat or poultry between uses. (976)|
|When I bring my groceries home, I refrigerate cold foods immediately. (996)|
|aNumber in parentheses is number of respondents for questionnaire item.|
Sociodemographic Differences in Safe Food Handling Practices
We found that adherences to safe practices were influenced by gender, race/ethnicity, age, marital status, and education. Here we present summaries of those influences. The comprehensive chi-square test results are shown in Table 3, following the summaries.
Significantly more men than women reported not engaging in the following safe food handling practices: using separate cutting boards (p = .033), hand washing (p = .031), keeping kitchen towels/sponges clean (p = .003), throwing out suspicious leftovers (p = .001), and washing cutting boards before use (p = .002).
Significantly higher percentages of respondents who self-identified as persons of color, compared to those who self-identified as White, indicated that they did not thaw meat in the refrigerator (p = .024) and did not pick up cold or frozen food last before checking out at the grocery (p = .003). Conversely, a significantly higher percentage of respondents who self-identified as White, compared to those who self-identified as persons of color, did not check food package dates (p = .044).
Additionally, participants aged 71 to 80 years were less likely to thaw meats in the refrigerator (p = .006) or refrigerate leftover food immediately (p = .034), compared to other age groups. A lower proportion of married participants, compared to nonmarried participants, reported thawing meat in the refrigerator (p = .006), but the opposite relationship was true for checking food package dates (p = .016). Finally, those with a lower education level were less likely to wash cutting boards between uses (p = .045) than those who had a higher education level.
|Sociodemographic variable||Percentage within group reporting "no/sometimes"||Χ2||p-value|
|Thaw meat in the refrigerator|
|Persons of color||67.5|
|Pick up cold food last before check out|
|Persons of color||61.9|
|Check dates on food packages|
|Persons of color||19.5|
|Use separate cutting boards|
|Refrigerate leftovers immediately|
|Wash hands before preparing food|
|Keep kitchen towels/sponges clean|
|Throw out suspicious leftovers|
|Wash cutting boards after contact with meat|
|College and above||5.0|
|High school or less||8.3|
Our study findings suggest that the sample of older adults we surveyed would benefit from food safety education topics targeting temperature control, food package sell-by/use-by dates, and cross-contamination. These findings align with those of Roy et al. (2016), who identified similar gaps related to safe food handling practices among community-residing older adults (e.g., those living in retirement communities or attending congregate meals) in the Midwest.
As others have done, we explored whether differences in safe food handling practices existed between respondents having different sociodemographic characteristics. Our findings showed food safety behaviors to be associated with gender, race/ethnicity, age, marital status, and education.
Gender was associated with several food safety practices, which may be attributable to lower food safety awareness regarding recommended safe food handling practices and/or risk perception among men. Research has indicated that males, compared to females, generally pay less attention to potential food safety hazards (Newman, Leon, Rebolledo, & Scallan, 2015) and are less likely to practice recommended food safety behaviors related to hand washing and cross-contamination prevention (Cates et al., 2009). Similarly, Anderson, Verrill, and Sahyoun (2011) reported that females are more likely than males to practice effective hand-washing behaviors and less likely to eat suspicious leftover and potentially risky food.
Race/ethnicity was associated with safe food handling practices related to temperature control (i.e., obtaining cold foods last at the grocery store) and food selection (i.e., reading package dates). Chang, Groseclose, Zaidi, and Braden (2009) conducted a 10-year ecological analysis and discovered that persons of color had a higher incidence of food-borne infections, which the researchers hypothesized was associated with socioeconomic status, food safety knowledge, and cultural differences. However, contrary to those findings and ours, Anderson et al. (2011) reported that older persons of color had better food safety practices compared to White older adults regarding hand washing, knowing the temperature of the refrigerator, understanding the importance of using a food thermometer, and not serving rare hamburgers. These researchers also reported that older persons of color had a higher perception of personal food safety risk compared to White older adults (Anderson et al., 2011). Due to these conflicting findings, further investigation is warranted to determine the role of race/ethnicity related to food safety behaviors so that culturally appropriate education programs can be developed.
Age, marital status, and educational status also influenced safe food handling practices in our sample of older adults. Anderson et al. (2011) reported that adults aged 60 years and older were more likely to follow recommended food safety practices than those younger than age 60. However, we found that adults between 71 and 80 years old were not likely to follow safe meat-thawing practices. In contrast to our findings related to marital status, Anderson et al. (2011) reported that older adults who live alone were less likely to follow recommended food temperature control practices.
Finally, we found that education status was associated with cutting board hygiene practices. Those with less education were less likely to report washing cutting boards, compared to those who were more educated. Our finding linking lower education with this food handling practice differs from other research examining education's influence on food safety practices. Anderson et al. (2011) reported that those with higher education were less likely to follow specific safe food handling practices than those with less education; for example, they found that higher education was associated with higher likelihood of eating potentially hazardous foods (e.g., undercooked hamburger). Given these contradictory findings, more research examining the role educational status has in safe food handling among older adults should be conducted.
The findings we report here are not generalizable due to the limited diversity of the participants and the survey questionnaire used. Majorities of study participants were White, were female, and resided in rural areas; these population segments are representative of older adults in the Midwest state under study but not nationally (U.S. Census Bureau, 2017). Additionally, convenience sampling from a group of older adults participating in a SNAP-Ed program may have resulted in recruiting older adults who were more interested in and aware of recommended health behaviors, including safe food handling practices. Furthermore, it is unknown whether the participants who responded "no" or "sometimes" selected the answer because they were not practicing the stated behavior or because they did not select and/or prepare their own food. Finally, the results presented here are based on self-report data, which may have included more affirmative responses due to social desirability bias. Despite these limitations, the study findings provide insight on what food safety topics may have applicability with community-residing older adults.
Implications and Conclusions
Our study findings suggest a need for food safety education for older adults targeting several recommended food handling practice concepts. Specific concepts to be covered include temperature control, cross-contamination, and product selection practices. In providing older adult–focused food safety education, program developers should pay special attention to creating food safety materials and curricula that relate to the target audience factors of gender, race/ethnicity, age, marital status, and education level.
Additionally, future surveys should include questions inquiring about specific food handling behaviors, such as those related to meal preparation and grocery shopping. Furthermore, research exploring safe food handling practices among racially and ethnically diverse older adults should be pursued.
LeLee Yap is now a clinical dietitian at Florida Hospital Orlando in Orlando, Florida.
We wish to thank the congregate meal participants who cooperated in our study. Our research is supported by the U.S. Department of Agriculture Supplemental Nutrition Assistance Program, in collaboration with the Iowa Department of Public Health and Iowa State University Extension and Outreach. The work completed by Ms. Yap and Dr. Francis was done as part of the U.S. Department of Agriculture National Institute of Food and Agriculture NE1439 Project, Changing the Health Trajectory for Older Adults through Effective Diet and Activity Modifications.
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