Discovery and development of educational strategies to encourage safe food handling behaviors in cancer patients

Knowledge, Attitude, and Practice in Preventing Infection Among Patients With Cancer Receiving Chemotherapy

BACKGROUND

Oncology patients receiving chemotherapy are at a high risk for developing infections. Identifying factors that predict infection practices among these patients can help improve the quality of care provided.

PURPOSE

The purpose of this study was to evaluate the knowledge, attitudes, and practices related to infection prevention in oncology patients receiving chemotherapy.

METHODS

A cross-sectional study was conducted among 170 patients with cancer.

RESULTS

The majority of participants had a low to moderate level of knowledge, with high levels of attitude and practice related to infection prevention. Knowledge was a significant predictor of attitude and practice, while attitude was a predictor of infection prevention practices. Knowledge and attitude emerged as mutual predictors, which could explain 23% of the variation in practice toward infection prevention (R2 = 0.230, P = .00).

CONCLUSIONS

Findings indicated that both knowledge and attitude were powerful predictors of practice toward infection prevention.

Managing the Risk of Foodborne Infections in Pediatric Patients with Cancer: Is the Neutropenic Diet Still an Option?

Infections pose a significant threat to morbidity and mortality during treatments for pediatric cancer patients. Efforts to minimize the risk of infection necessitate preventive measures encompassing both environmental and host-focused strategies. While a substantial number of infections in oncologic patients originate from microorganisms within their native microbiological environment, such as the oral cavity, intestines, and skin, the concrete risk of bloodstream infections linked to the consumption of contaminated food and beverages in the community cannot be overlooked. Ensuring food quality and hygiene is essential to mitigating the impact of foodborne illnesses on vulnerable patients. The neutropenic diet (ND) has been proposed to minimize the risk of sepsis during neutropenic periods. The ND aims to minimize bacterial entry into the gut and bacterial translocation. However, a standardized definition for ND and consensus guidelines for specific food exclusions are lacking. Most centers adopt ND during neutropenic phases, but challenges in achieving caloric intake are common. The ND has not demonstrated any associated benefits and does not ensure improved overall survival. Consequently, providing unified and standardized food safety instructions is imperative for pediatric patients undergoing hematopoietic cell transplantation (HCT). Despite the lack of evidence, ND is still widely administered to both pediatric and adult patients as a precautionary measure. This narrative review focuses on the impact of foodborne infections in pediatric cancer patients and the role of the ND in comparison to food safety practices in patients undergoing chemotherapy or HCT. Prioritizing education regarding proper food storage, preparation, and cooking techniques proves more advantageous than merely focusing on dietary limitations. The absence of standardized guidelines underscores the necessity for further research in this field.

Dietetics Student Perceptions of Food Safety Communication to Vulnerable Populations: An International Study

Registered dietitians can play an important role in delivering food safety information to vulnerable population groups. Although dietetic students are reported to perceive food safety to be important for vulnerable population groups, little is known regarding their attitudes toward their role in the delivery of food safety information. Therefore, the purpose of this study was to determine and evaluate the perceptions of dietetic students regarding their role in food safety communication to vulnerable populations from three international institutions. A total of 208 dietetics students participated in the study from Columbus, Ohio, USA (n = 100), Cardiff, Wales, UK (n = 78), and Beirut, Lebanon (n = 30). Predominantly, the students in this study had positive attitudes toward the importance of food safety for vulnerable groups, although more students from Lebanon were skeptical that vulnerable patients were more susceptible to foodborne infections than the general populations (p < 0.001). Data indicated confidence and understanding of food safety principles and a willingness to learn more about food safety for these groups, however, some students in the UK (30%) and USA (31%) were not confident that they could effectively communicate food safety to vulnerable patients. Based on the findings in this and previous studies, adjustments are recommended to the requirements for food safety knowledge among dietetic students to include food safety counseling competency.

Assessing Existing Food Safety Resources with United Kingdom-Based Chemotherapy Patients and Family Caregivers for Future Learning Purposes

ABSTRACT

Because the incidence of foodborne infection is more prevalent among cancer patients and the domestic kitchen is a contributor to foodborne infection, appropriate domestic food safety practices are needed to safeguard this at-risk population. Although patients are aware of the increased risk of infection, previous self-reported data indicate potential food safety malpractices among patients and family caregivers, thus suggesting the need for targeted food safety information. However, existing United Kingdom resources provide inconsistent and insufficient food safety information. Involvement of intended end users in the cocreation of interventions increases potential effectiveness. Qualitative data were collated from in-depth interviews and a focus group with United Kingdom chemotherapy patients and family caregivers (n = 35) to determine perceptions and preferences for food safety information by evaluating existing food safety resources from international providers (n = 12). Although participants liked digital interventions (e.g., Web sites and videos), traditional paper-based leaflets were perceived as the most beneficial because they could be referred to on repeated occasions. Despite the drawbacks associated with some resources, combining approaches in a multiresource intervention was favored by patients and family caregivers. Ensuring patients are not overwhelmed with excessive information was important. Short, logical, engaging, educational, and entertaining information to evoke an interest in the topic was preferred. Utilization of graphics to supplement descriptive information may enhance comprehensibility. Interventions need to be appropriate for patients and caregivers, and delivery by trusted health care professionals may enhance the credibility of the message. Preferred approaches to facilitate targeted food safety communication were identified, and these findings can be utilized to cocreate targeted food safety interventions for chemotherapy patients and family caregivers.

HIGHLIGHTS

Awareness and Attitudes of Student Dietitians in Lebanon, UK and USA towards Food Safety

Allied health professionals such as dietitians can play a critical role in providing food safety advice to vulnerable consumers. To maximize food-related health and wellbeing, food needs to be safe and nutritious; consequently, food safety is referred to in international curricula for the training of dietitians. The purpose of this study was to explore the awareness and attitudes of student dietitians from three international institutions towards food safety. A total of 207 student dietitians participated in the study from Columbus, OH, USA (n = 99), Cardiff, Wales, UK (n = 78) and Beirut, Lebanon (n = 30). Completion of the study established that the students in three dietetic training programs lacked awareness of key food safety concepts. Close to half (43%) were not familiar with Campylobacter, with the USA students being significantly less knowledgeable (p < 0.001) with 58% being unaware of the pathogen. Understanding of safe handling of leftovers was the lowest for the students in all institutions; only 46% described appropriate reheating practices, with significantly lower (p < 0.001) understanding in Lebanon (28%). The students reported a good understanding of vulnerable populations and perceived food safety to be important for these groups. However, the knowledge of certain high-risk foods was lacking. For instance, 69% of students thought that fresh squeezed juices and smoothies made with raw fruits and vegetables were safe for vulnerable patients, with the UK students being the least familiar with this risk (16%). This is the first study of its kind to take an international perspective of student dietitian food safety awareness and attitudes; the findings are important to dietetic food safety educators and recommendations are made to further explore the interpretation of food safety requirements in international dietetic curricula. Future studies should extend student dietetic research to address attitudes, self-efficacy and the overall readiness to deliver food safety advice to the patients and the community.

Assessment of Food Safety Knowledge and Behaviors of Cancer Patients Receiving Treatment

Cancer patients receiving treatment are at a higher risk for the acquisition of foodborne illness than the general population. Despite this, few studies have assessed the food safety behaviors, attitudes, risk perceptions, and food acquisition behaviors of this population. Further, no studies have, yet, quantified the food safety knowledge of these patients. This study aims to fill these gaps in the literature by administering a thorough questionnaire to cancer patients seeking treatment in three hospitals in a Midwest, metropolitan area. Demographic, treatment, food security, and food safety knowledge, behaviors, attitudes, risk perceptions, and acquisition information was assessed for 288 patients. Specific unsafe attitudes, behaviors, and acquisition practices were identified. Most notable is that 49.4% (n = 139) of participants were not aware that they were at increased risk of foodborne infection, due to their disease and treatment. Additionally, though patients exhibited a general understanding of food safety, the participant average for correctly answering the food safety questions was 74.77% ± 12.24%. The section concerning food storage showed lowest participant knowledge, with an average score of 69.53% ± 17.47%. Finally, patients reporting low food security also reported a higher incidence of unsafe food acquisition practices (P < 0.05). These findings will help healthcare providers to better educate patients in the food safety practices necessary to decrease risk of foodborne infection, and to provide targeted food safety education to low-food-security patients.

Listeriosis in Pregnancy: Practitioners' Food Safety Counselling Practices to Pregnant Women

OBJECTIVE

The relative risk of invasive listeriosis in pregnant women is approximately 20 times greater than the general population, and listeriosis during pregnancy can have negative consequences for pregnant women, their fetuses, and their newborns. Health care providers are valuable sources of information, but published data suggest that most providers are unaware of the risk factors for listeriosis or its propensity for pregnant women, and they do not counsel their pregnant patients about risks. The objective of this study was to determine knowledge and practices of Canadian perinatal care providers on food safety counselling to pregnant women.

METHODS

An anonymous bilingual online questionnaire that sought information about awareness, knowledge of risk factors, practices for counselling pregnant women, and practitioners' learning needs with regard to listeriosis was sent to 3199 nurses, midwives, family physicians, and obstetrician/gynaecologists in Canada, with a response rate of 24.4%.

RESULTS

Most respondents had heard of listeriosis, provided prenatal care, and attended deliveries. Rates of awareness of listeriosis were the same among professions and were independent of years in practice, whether practice was urban or rural, and province. One third of the respondents (35.7%) were aware that listeriosis was more common in pregnant women; a minority (18.7%) correctly identified the incubation period for listeriosis and the stage in pregnancy in which women are at highest risk (30.4%). Those respondents who did not counsel women about the risks of listeriosis during pregnancy reported a lack of information or knowledge as the main reason.

CONCLUSION

Advising pregnant women about behaviours and lifestyle habits to prevent infectious diseases remains important, and information about preventive practices needs to be complete and adequate. The health care providers who participated in this study did express a clear need for information related to food safety during pregnancy and listeriosis, as supported by their lack of knowledge in some areas. If that lack is remedied, the knowledge gained could improve counselling practices.

An assessment of food safety information provision for UK chemotherapy patients to reduce the risk of foodborne infection

OBJECTIVES

Given the increased risk of foodborne infection to cancer patients receiving chemotherapy treatment, and the risk of listeriosis reportedly five-times greater to this immunocompromised patient group, there is a need to ensure the implementation of domestic food safety practices among chemotherapy patients and their family caregivers. However, information regarding the adequacy of resources to inform and enable patients to implement domestic food safety practices to reduce the risk of foodborne infection is limited. Consequently, this study aimed to evaluate the provision of food safety information available to UK chemotherapy patients.

STUDY DESIGN

In-depth semi-structured interviews and content analysis of online patient information resources.

METHODS

Interviews with patients and family caregivers (n = 15) were conducted to explore food-related experiences during chemotherapy treatment. Online food-related information resources for chemotherapy patients (n = 45) were obtained from 35 of 154 National Health Service chemotherapy providers in England, Scotland, and Wales, the Department of Health (DoH) and three of 184 identified UK cancer charities. Identified food-related information resources were reviewed using a content-analysis approach to assess the inclusion of food safety information for chemotherapy patients.

RESULTS

In-depth interviews established that many patients indicated awareness of immunosuppression during treatment. Although patients reported practicing caution to reduce the risk of communicable diseases by avoiding crowded spaces/public transport, food safety was reported to be of minimal concern during treatment and the risk of foodborne infection was often underestimated. The review of online food-related patient information resources established that many resources failed to highlight the increased risk of foodborne infection and emphasize the importance of food safety for patients during chemotherapy treatment. Considerable information gaps exist, particularly in relation to listeriosis prevention practices. Cumulatively, information was inconsistent, insufficient, and varied between resources.

CONCLUSION

The study has identified the need for an effective, standardized food safety resource specifically targeting chemotherapy patients and family caregivers. Such intervention is essential to assist efforts in reducing the risks associated with foodborne infection among chemotherapy patients.

Explaining Consumer Safe Food Handling Through Behavior-Change Theories: A Systematic Review

Consumers often engage in unsafe food handling behaviors at home. Previous studies have investigated the ability of behavior-change theories to explain and predict these behaviors. The purpose of this review was to determine which theories are most consistently associated with consumers' safe food handling behaviors across the published literature. A standardized systematic review methodology was used, consisting of the following steps: comprehensive search strategy; relevance screening of identified references; confirmation of relevance and characterization of relevant articles; risk-of-bias assessment; data extraction; and descriptive analysis of study results. A total of 20 relevant studies were identified; they were mostly conducted in Australia (40%) and the United States (35%) and used a cross-sectional design (65%). Most studies targeted young adults (65%), and none focused on high-risk consumer groups. The outcomes of 70% of studies received high overall risk-of-bias ratings, largely due to a lack of control for confounding variables. The most commonly applied theory was the Theory of Planned Behavior (45% of studies), which, along with other investigated theories of behavior change, was frequently associated with consumer safe food handling behavioral intentions and behaviors. However, overall, there was wide variation in the specific constructs found to be significantly associated and in the percentage of variance explained in each outcome across studies. The results suggest that multiple theories of behavior change can help to explain consumer safe food handling behaviors and could be adopted to guide the development of future behavior-change interventions. In these contexts, theories should be appropriately selected and adapted to meet the needs of the specific target population and context of interest.

Use of Health Belief Model Variables To Examine Self-Reported Food Handling Behaviors in a Sample of U.S. Adults Attending a Tailgate Event

Unsafe food handling behaviors are common among consumers, and, given the venue, individuals attending a tailgating event may be at risk for foodborne illness. The objective of this study was to measure the association between Health Belief Model variables and self-reported usual food handling behaviors in a convenience sample of men and women at a tailgate event. Participants (n = 128) completed validated subscales for self-reported food handling behaviors (i.e., cross-contamination, sanitation), perceived threat of foodborne illness (i.e., perceived severity, perceived susceptibility), and safe food handling cues to action (i.e., media cues, educational cues). Perceived severity of foodborne illness was associated with safer behaviors related to sanitation (r = 0.40; P < 0.001) and cross-contamination (r = 0.33; P = 0.001). Perceived severity of foodborne illness was also associated with exposure to safe food handling media cues (r = 0.20; P = 0.027) but not with safe food handling educational cues. A large proportion of participants reported that they never or seldom (i) read newspaper or magazine articles about foodborne illness (65.6%); (ii) read brochures about safe ways to handle food (61.7%); (iii) see store displays that explain ways to handle food (51.6%); or (iv) read the "safe handling instructions" on packages of raw meat and poultry (46.9%). Perceived severity of foodborne illness was positively related to both dimensions of safe food handling as well as with safe food handling media cues. Except for the weak correlation between media cues and perceived severity, the relationships between safe food handling cues and perceived threat, as well as between safe food handling cues and behaviors, were nonsignificant. This finding may be due, in part, to the participants' overall low exposure to safe food handling cues. The overall results of this study reinforce the postulate that perceived severity of foodborne illness may influence food handling behaviors.

Reporting of foodborne illness by U.S. consumers and healthcare professionals

During 2009-2010, a total of 1,527 foodborne disease outbreaks were reported by the Centers for Disease Control and Prevention (CDC) (2013). However, in a 2011 CDC report, Scallan et al. estimated about 48 million people contract a foodborne illness annually in the United States. Public health officials are concerned with this under-reporting; thus, the purpose of this study was to identify why consumers and healthcare professionals don't report foodborne illness. Focus groups were conducted with 35 consumers who reported a previous experience with foodborne illness and with 16 healthcare professionals. Also, interviews with other healthcare professionals with responsibility of diagnosing foodborne illness were conducted. Not knowing who to contact, being too ill, being unsure of the cause, and believing reporting would not be beneficial were all identified by consumers as reasons for not reporting foodborne illness. Healthcare professionals that participated in the focus groups indicated the amount of time between patients' consumption of food and seeking treatment and lack of knowledge were barriers to diagnosing foodborne illness. Issues related to stool samples such as knowledge, access and cost were noted by both groups. Results suggest that barriers identified could be overcome with targeted education and improved access and information about the reporting process.

Nurses and dietitians differ in food safety information provided to highly susceptible clients

OBJECTIVE

To determine content, education channels, and motivational factors that influence what health professionals teach about safe food handling to populations who are highly susceptible for foodborne illnesses. To assess the differences in information provided by health professionals to highly susceptible populations.

DESIGN

Descriptive, cross-sectional, Web-based survey.

SETTING

National convenience sample from across the United States.

PARTICIPANTS

Registered nurses (RNs; n = 232) and registered dietitians (RDs; n = 267).

MAIN OUTCOME MEASURE(S)

Content, motivation, and education channels used to educate highly susceptible populations.

ANALYSIS

Various nonparametric tests were applied to measure differences. Significance was declared at P < .05.

RESULTS

Although both RDs and RNs were providing some food safety information to their high-risk clients, RDs had more training than RNs in safe food handling and were more likely to provide comprehensive food safety messages to their highly susceptible clients; however, neither professional type provided consistent food safety information to patients at high risk for foodborne illness.

CONCLUSIONS AND IMPLICATIONS

There is a need for more information about what motivates the health professional to teach safe food handling and a need for a universally adopted, evidence-based practice for teaching safe food handling to patients at high risk for foodborne illness.

Invasive listeriosis in the Foodborne Diseases Active Surveillance Network (FoodNet), 2004-2009: further targeted prevention needed for higher-risk groups

BACKGROUND

Listeriosis can cause severe disease, especially in fetuses, neonates, older adults, and persons with certain immunocompromising and chronic conditions. We summarize US population-based surveillance data for invasive listeriosis from 2004 through 2009.

METHODS

We analyzed Foodborne Diseases Active Surveillance Network (FoodNet) data for patients with Listeria monocytogenes isolated from normally sterile sites. We describe the epidemiology of listeriosis, estimate overall and specific incidence rates, and compare pregnancy-associated and nonpregnancy-associated listeriosis by age and ethnicity.

RESULTS

A total of 762 listeriosis cases were identified during the 6-year reporting period, including 126 pregnancy-associated cases (17%), 234 nonpregnancy-associated cases(31%) in patients aged <65 years, and 400 nonpregnancy-associated cases (53%) in patients aged ≥ 65 years. Eighteen percent of all cases were fatal. Meningitis was diagnosed in 44% of neonates. For 2004-2009, the overall annual incidence of listeriosis varied from 0.25 to 0.32 cases per 100,000 population. Among Hispanic women, the crude incidence of pregnancy-associated listeriosis increased from 5.09 to 12.37 cases per 100,000 for the periods of 2004-2006 and 2007-2009, respectively; among non-Hispanic women, pregnancy-associated listeriosis increased from 1.74 to 2.80 cases per 100,000 for the same periods. Incidence rates of nonpregnancy-associated listeriosis in patients aged ≥ 65 years were 4-5 times greater than overall rates annually.

CONCLUSIONS

Overall listeriosis incidence did not change significantly from 2004 through 2009. Further targeted prevention is needed, including food safety education and messaging (eg, avoiding Mexican-style cheese during pregnancy). Effective prevention among pregnant women, especially Hispanics, and older adults would substantially affect overall rates.

Health professionals' knowledge and understanding about Listeria monocytogenes indicates a need for improved professional training

Listeria monocytogenes causes listeriosis, an uncommon but potentially fatal disease in immunocompromised persons, with a public health burden of approximately $2 billion annually. Those consumers most at risk are the highly susceptible populations otherwise known as the immunocompromised. Health professionals have a considerable amount of interaction with the immunocompromised and are therefore a valuable resource for providing appropriate safe food handling information. To determine how knowledgeable health professionals are about Listeria monocytogenes, a nationwide Web-based survey was distributed targeting registered nurses (RNs) and registered dietitians (RDs) who work with highly susceptible populations. Responses were received from 499 health professionals. Knowledge and understanding of Listeria monocytogenes was assessed descriptively. Parametric and nonparametric analyses were used to detect differences between RNs and RDs. The major finding is that there are gaps in knowledge and a self-declared lack of understanding by both groups, but especially RNs, about Listeria monocytogenes. RDs were more likely than RNs to provide information about specific foods and food storage behaviors to prevent a Listeria infection. Notably, neither group of health professionals consistently provided Listeria prevention messages to their immunocompromised patients. Pathogens will continue to emerge as food production, climate, water, and waste management systems change. Health professionals, represented by RNs and RDs, need resources and training to ensure that they are providing the most progressive information about various harmful pathogens; in this instance, Listeria monocytogenes.

Qualitative studies of the food safety knowledge and perceptions of transplant patients

Organ and stem cell transplant patients are at risk for foodborne illness due to disease and medically induced immunosuppression. The food safety knowledge and informational needs of these groups have not been documented in the literature. The objectives of this study were to assess transplant patients' food safety knowledge and perceptions, to probe the likelihood of practicing safe food handling behavior, and to test an educational strategy for future food safety interventions aimed at transplant patients. Subjects were organ or stem cell transplant patients, or their family care providers. Research was conducted in inpatient or outpatient facilities at a large, Midwestern United States comprehensive cancer and transplant center. Differences in survey data between the organ and stem cell transplant groups were determined by Student's t tests. Ethnographic methods were used to analyze qualitative focus groups and interview data for themes. Organ transplant patients had less motivation to follow food safety recommendations than did stem cell transplant patients, and they were more likely to consume risky foods. Stem cell transplant patients overall had a better understanding of their susceptibility to foodborne illness and had better prepared themselves with the knowledge and behavior changes needed to protect their health. Educational materials aimed at communicating food safety information for transplant patients were evaluated by patients and judged acceptable. This study found that organ transplant and stem cell transplant patients are distinct patient populations, with differing perceptions regarding the seriousness of foodborne illness and willingness to adopt preventative food handling practices. Population differences should be accounted for in food safety educational strategies.