Running head: Food Safety for Older Adults

Food Safety for Community Living Older Adults

Shayne Barker & Kellen Lewis

University of Utah Department of Occupational Therapy

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Foodborne illness rates are estimated to be one in four people in the United States

(Kendall, Hillers, and Medeiro, 2006). Typically, these illnesses last a few days of discomfort,

vomiting, and diarrhea, but for older adults it can easily put them in the hospital. Hospitalization

rates for foodborne illnesses are highest for adults over the age of 75, and this age demographic

is 33x more likely to die while hospitalized for gastroenteritis. It is estimated that by 2030 one in

five people will be over the age of 65 in the United States. With this growing population

demographic that is at a higher risk for hospitalization it is important for them to know the risks

of foodborne illnesses and the best prevention techniques.

Many factors impact these increased rates of illness among older adults including, aging

immune system, chronic disease, and risky food behaviors (Kendall, Hillers, and Medeiro, 2006).

Older adults may be handling food as they always have, but because of the changes in their body

they are putting themselves at higher risk for sickness or death. According to Kendall, Hillers,

and Medeiro (2006) older adults are less likely to perform hand hygiene and are more likely to

have problems with cross-contamination between raw foods. Since older adults are at such a high

risk for sickness that could be avoided through proper training the purpose of this wellness group

is to educate older adults to food safety practices that they can implement into everyday food

preparation.

Evidence

According to Oyarzabel and Backert (2012), there are limited widespread programs to

address food safety for any demographic. Most of the resources that have been implemented are

in textbooks, and are secondary to primary course content. That is to say that if the book is on

cooking there is a chapter on food safety, but it is not the entire focus of the course. Kamp,

Wellmen, and Russell (2010) overviewed all of the nutritional programs for community-residing
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older adults, and found that there is a significant lack in programs addressing food safety

specifically. Since food safety is secondary to program focus there isn’t a lot of evidence on the

effectiveness of current programs.

Due to this lack of specific programs in order to develop this program it is important to

focus evidence that supports on who is at most risk, what should be the focus of course content,

and how should the information be presented. In a self-report study on the effectiveness of public

health efforts for safe food handling among older adults, Hanson and Benedict (2002) found that

programs that focus on instructing participants on how to handle food safely instead of the risks

were more effective at creating a change. Cues to action increased the likelihood of older adults

incorporating what they learned more than being scared into changing. Anderson, Verrill, and

Sahyoun (2011) found that as someone gets older they are more likely to follow safety

recommendations if they understand them clearly. Surprisingly, these researchers also found that

higher educated, higher SES, and men were at the most risk for not following food safety

standards. Kendall et al. (2006), also found that adults with cognitive decline were at higher risk

to engage in poor food handling behaviors.

Cates et al. (2009) in their examination of food safety knowledge found that older adults

lacked education on proper food storage, using a meat thermometer, and checking the

temperature for the refrigerator. Dickinson, Wills, Meah, and Short (2014) and Evans and

Redmond (2016) also found strong evidence that older adults were most at risk for poor food

storage and food temperatures. In particular they found that ready to eat foods posed the most

risk because they are less likely to heated up to the proper temperature and are less likely to be

stored correctly (Evans and Redmond, 2016).

General Description
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Our wellness program will consist of four sessions that will be 30 to 40 minutes in length

and held once a week. The name of the program will be, “The Greatest Offense is a Great

Defense: A Food Safety Program”. The basis for the length of the sessions is to keep the focus,

interest and attention of our targeted population. With older adults, attention and interest could

be shortened, thus it is necessary to keep sessions short, concise and to the point. Holding the

class once a week gives ample time in between sessions for all participants to implement food

safety practices, develop any questions and schedule further participation in the program. Our

target population is community dwelling adults, so the delivery system of this program will be

community based, desired physical location would be a community senior citizen center.

The four sessions will be as follows: introduction, food storage and expirations, proper

food preparation and sanitation, and safe food temperatures. These sessions are pertinent to older

community dwelling adults due to an increase in food poisoning hospitalizations (Anderson,

Verrill, & Sahyoun, 2011).

The first session, titled “Knowledge is Power”, will focus on what food safety is and the

objective of the program. This session will also explain why older adults need to be food safety

conscious, especially considering many older adults place “common-sense” knowledge on equal

footing as “expert” knowledge in regards to food safety recommendations (Dickinson, Wills,

Meah, & Short, 2014). A pre-test will be administered to get a baseline of food safety knowledge

and be administered at the end of the program to see if the program was effective in promoting

food safety. We will also be educating on Salmonella and Listeria and what foods are most

associated with them and signs and symptoms of infection. This will set a foundational

knowledge that can be referenced in the subsequent sessions.

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Food storage and expirations session, titled “You got to keep them separated”, will focus

on proper storage of different kinds of foods and how to determine if food is still safe for

consumption. It has been shown that majority of older adults are aware of the importance of

proper food storage and the utilization of expirations dates on packaged food, but majority of

older adults don’t know what the proper set temperature on a refrigerator should be and that food

is still good after the expiration date (Evans & Redmond, 2016).

The third session, titled “‘Clean’ eating”, focuses on proper food preparation and

sanitation to prevent contraction of foodborne pathogens. The session will include using separate

surfaces and tools for different meat, fruit and vegetable preparation. It will also focus on proper

sanitation of surfaces, tools and hands.

The final session, titled “Let me take your temperature”, will educated older adults on

temperature guidelines for meat and other raw food ingredients. This session will give examples

of different food temperature gauges and the proper use of them. Although most older adults are

good at making sure meat is done, there are many who prefer undercooked foods or are unaware

of temperature recommendations (Kendall, Hillers, & Medeiro, 2006). Lastly, the post-test will

be administered to see if the participants scored better than their pretest. We will also be giving

them questionnaires to understand their perspective on the effectiveness of the program.

The main reason why occupational therapy should be involved in food safety is because

meal preparation is a defined area of occupation; which is, “Planning, preparing, and serving

well-balanced, nutritious meals and cleaning up food and utensils after meals” (AOTA, 2014).

Meal preparation holds meaning to many adults, especially those who are older and want to

continue to live independently. But, to live independently as an older adult, safety should be a

top priority, even in meal preparation. Most incidents of food poisoning in older adults is due to
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either a gap in knowledge or the effects of cognitive decline (Kendall, Hillers, & Medeiro, 2006).

OTs are equipped to provide skilled therapy to remediate, promote or modify food safety skills in

the face of cognitive decline. Not only can OTs provide older adults with these skills through the

occupation of food prep, but generalize these skills to all areas of their occupations.

Theories/models

As part of this program we are utilizing two different models to address the needs of

group members. The first is the Person, Environment, Occupation (PEO) Model which focuses

on congruence and interaction between these three components (Law et al., 1996). We are

focusing on the person by educating the participants on proper food temperatures, hand hygiene,

cross-contamination, and proper food storage. The environment can also be a focus of

intervention because participants may need to change refrigerator temperatures or where they

prep their food to ensure that it is being done safely.

The second model we are utilizing is the Health Belief Model, which focuses on people’s

perceived risk of an activity, and their perceived control over that risk (Rosenstock, 1974). First,

people need to understand that some behavior poses a risk to their health, and then they need to

understand that they have the ability to change that outcome through their effort. As part of our

program we are focusing on increasing the participant’s awareness of the risks involved when

not handling food safely, and help them know what steps they can take to avoid those risks.

Occupational Balance

We feel that occupational balance is achieved through food safety education by

offering the opportunity of older adults to participate in meal preparation of their choosing,

instead of having to rely on pre-packaged/pre-made food items due to lack of food safety
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preparation confidence or fear. This program gives older adults the ability to diversify their diets

to their liking and promote homemade meals.

OTPF/AOTA Position

According to the OTPF (AOTA, 2014) a health promotion program is designed to enrich

activities for a general population that will enhance their occupational performance. For older

adults being able to prepare their own meals safely can help enhance their ability to safely

participate in a meaningful daily activity and enhance the already existing skill of cooking by

allowing more confidence in their food safety.

Additionally, the American Occupational Therapy Association (AOTA) said:

It is important that occupational therapy practitioners promote a healthy lifestyle for all

individuals and their families, including people with physical, mental, or cognitive

impairments...occupational therapy practitioners possess the basic knowledge and skills

to carry out health promotion interventions to prevent injury and maximize well-being

(AJOT, 2013).

Through a food safety program, occupational therapist can promote a healthy lifestyle by

lowering the incidence of foodborne illness in older adults through education through a primary

preventive program.

Value to patients, payers, and healthcare facilities

As stated above, a food safety program will give patients a peace of mind by knowing

that they carry less of a chance of foodborne infection when preparing meals through the skills

that they learn. The value of that peace of mind will encourage and promote older adults to

continue to cook homemade meals, thus preserving the occupation of meal preparation and

increase community dwelling independence.

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The payers and healthcare facilities would benefit greatly from this program because it

would lower the expenditure costs on older adults. As previously mentioned, older adults have

higher hospitalizations caused by foodborne illness due to lowered immune systems (Cates et al.,

2009). Therefore, a food safety program will lower insurance and facility cost by lowering the

number of hospitalizations of illness that can be prevented.

Overall Goals and Measurable Objectives

Program goal: To empower older adults in the implementation of food safety skills into

everyday healthy meal preparation

Objectives: By the 4th session 80% of individuals will score 2 points higher on food

safety post assessment.

By the 4th session 70% of individuals will independently measure correct temperature of two

different kinds of food.

Session outline

The session outline for “You got to Keep Them Separated”: The first 15 minutes will be

instruction on following good food expiration practices. A handout will be given that lists basic

foods’ edible shelf life from each of the major food groups. Instruction will then be given on how

to find the “sell by” date on a variety of food packages. Different kinds of food packaging will be

brought in so that the participants can practice finding the date and a game on who can find the

date the fastest. Lastly, we will emphasize the importance of following the sell by date always in

determining food edibility and to not trust visual, gustatory, or olfactory senses since older adults

may be experiencing deficits in those senses.

The next 10 minutes will be showing a slideshow of refrigerators full of food and their set

temperature. Instruction will be given on the proper temperature for the refrigerator and the
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freezer and proper storage of food in the refrigerator. Instruction will include storing high risk

foods on the top shelf of fridge. Next, having ready to eat foods, followed by fresh produce, and

finally raw meats. Also including proper storage containers such as tupperware or tightly sealed,

zipper plastic bags for any foods that do not have original containers they were bought it.

The last 20 minutes we will have a refrigerator organized with improper storage

techniques and the wrong temperature set. We will then have the participants work as a group to

identify the problem areas and reorganize the refrigerator following the above guidelines.

Program effectiveness measure

In order to measure this program’s effectiveness, we plan to use both quantitative and

qualitative post-assessments. The purpose of these questions are to explore how to present the

information in a way that is engaging to the members, and use the information to incorporate in

future classes to continually improve the delivery system. The quantitative information will be

gathered using likert scales to assess if the course adequately taught the content, and if the

information was easy to incorporate into daily food preparation. The qualitative information will

be gathered with free response questions addressing more of the teaching style of the group

leaders. See Appendix A for the questionnaire.

Conclusion

There is a lack of programs to address food safety in community dwelling older adults.

We feel that this program could set a foundation to address that need, in order to decrease

hospitalization of older adults, and increase older adults’ competence in an important everyday

activity. By participating in this program, it will enable older adults to remain independent longer

and assist in the development of performance skills related to occupational engagement.

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References

American Occupational Therapy Association. (2014). Occupational therapy practice framework:

domain & process (3rd ed.). American Occupational Therapy Association, 68.

Anderson, A. L., Verrill, L. A., & Sahyoun, N. R. (2011). Food Safety Perceptions and Practices
of Older Adults. Public Health Reports, 126(2), 220–227.

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.

Dickinson, A., Wills, W., Meah, A., & Short, F. (2014). Food safety and older people: the
Kitchen Life study. British Journal Of Community Nursing, 19(5), 226-232.

Evans, E. W., & Redmond, E. C. (2016). Older Adult Consumer Knowledge, Attitudes, and
Self-Reported Storage Practices of Ready-to-Eat Food Products and Risks Associated
with Listeriosis. Journal of Food Protection, 79(2), 263-272.
doi:10.4315/0362-028x.jfp-15-312

Hanson, J. A., & Benedict, J. A. (2002). Use of the Health Belief Model to examine older adults'
food-handling behaviors. Journal of Nutrition Education and Behavior, 34, S25-S30.

Kamp, B. J., Wellman, N. S., & Russell, C. (2010). Position of the American Dietetic
Association, American Society for Nutrition, and Society for Nutrition Education: food
and nutrition programs for community-residing older adults. Journal of nutrition
education and behavior, 42(2), 72-82.

Kendall, P. A., Hillers, V. V., Medeiro, L. C., (2006). Food safety guidance for older adults. Clin
Infect Dis, 42(9): 1298-1304. doi: 10.1086/503262

Kennedy, J., Jackson, V., Blair, I. S., McDowell, D. A., Cowan, C., & Bolton, D. J. (2005). Food
safety knowledge of consumers and the microbiological and temperature status of their
refrigerators. Journal of food protection, 68(7), 1421-1430.

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The
Person-Environment-Occupation Model: a transactive approach to occupational
performance. Canadian Journal of Occupational Therapy, 63, 9-23.
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Lobb, A. E., Mazzocchi, M., & Traill, W. B. (2007). Modelling risk perception and trust in food
safety information within the theory of planned behaviour. Food Quality and Preference,
18(2), 384-395.

Occupational Therapy in the Promotion of Health and Well-Being. (2013). American Journal of
Occupational Therapy, 67(6_Supplement). doi:10.5014/ajot.2013.67s47

Oyarzabal, O. A., & Backert, S. (2012). Food Safety Resources. In Microbial Food Safety (pp.
235-239). Springer New York.

Rosenstock, I. (1974). Historical origins of the health belief model. In M. Becker (Ed.), The
Health Belief Model and personal behavior. Thorofare, NJ: SLACK.

Wilcock, A., Pun, M., Khanona, J., & Aung, M. (2004). Consumer attitudes, knowledge and
behaviour: a review of food safety issues. Trends in Food Science & Technology, 15(2),
56-66.
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Appendix A

How likely are you to use this information in your daily food preparation:

Very likely Somewhat likely Not likely Very unlikely

This class was effective in teaching food safety:

Strongly agree Agree Disagree Strongly disagree

This program has changed the way I previously stored, handled, and prepared my food:

Strongly agree Agree Disagree Strongly disagree

The program was well organized:

Strongly agree Agree Disagree Strongly disagree

The program was interesting and engaging:

Strongly agree Agree Disagree Strongly disagree

I would recommend this program to others:

Strongly agree Agree Disagree Strongly disagree

What part of the class did you feel was most effective?

What part of the class did you feel was ineffective?

What changes would you recommend to make this program better?

What was your favorite part of the classes?

How did the teaching style match/not match with your learning style?