Health education and food safety behavior in the university setting. (Features).

Introduction

According to the Centers for Disease Control and Prevention (CDC) (1997), "Colleges and universities are important settings for delivering health promotion education and services to many young adults." To assess the health behaviors of young adults and adolescents, CDC developed the Youth Risk Behavior Surveillance System (YRBSS). The YRBSS assesses and monitors behavior in six categories: 1) injuries, 2) tobacco use, 3) alcohol and drug use, 4) sexual behavior, 5) diet and nutrition, and 6) physical activity. The YRBSS has been regularly used to survey students in grades 9 through 12; in 1995, CDC conducted the first YRBSS among college students (CDC, 1997). While the YRBSS covers high-priority health issues for college campuses as discussed by Gordon (1995), notably missing from these priorities is environmental health.

Environmental health is not prominent in health education curricula at any grade level, from pre-school (D'Agostino, D'Andrea, Lieberman, Sprance, & Williams, 1999) to graduate programs in health education (Pope & Brookins-Fisher, 1999). Although a high percentage of primary and secondary schools include health education in their curricula (Grunbaum et al., 1998), environmental health education is not a component of most health education learning episodes. CDC does not mention environmental health in its guidelines for comprehensive school health education (CDC, 2001); however, there is evidence that primary- and secondary-school (K-12) science teachers believe that environmental health science education should receive more emphasis at their schools (Morrone, 2001).

The university setting offers unprecedented opportunities to provide environmental health education because there is a captive audience of young adults and a forum in which many of them can be reached at one time. Unfortunately, environmental health issues in general, and food safety in particular, are often overlooked in general university health promotion classes. Although introductory health texts cover these subjects, the coverage is modest, amounting to a couple of pages in texts that are close to 700 pages long (Donatelle & Davis, 2000; Insel & Roth, 1998; Payne & Hahn, 2000). Furthermore, the breadth of information to be covered in a university introductory health class requires the instructor to prioritize topics, and it falls to his or her discretion whether to include environmental health topics.

The YRBSS noted above was preceded by the Behavioral Risk Factor Surveillance Survey (BRFSS) developed by CDC in 1984 and used in all states by 1994. The BRFSS is a series of core questions related to health behaviors of adults; states have the discretion to add questions to cover additional topics of interest. In 1995, CDC worked with the Food and Drug Administration (FDA) and state and local health departments to develop questions related to food safety. The 12 questions about food handling shown in Figure 1 were added and tested in eight states, revealing interesting information about food-handling behaviors (Yang et al., 1998). Several of the questions in the survey pertained to labeling requirements for safe handling of meat and poultry products.

On March 28, 1994, the Food Safety Inspection Service of the U.S. Department of Agriculture (USDA) issued final rules for safe-handling labels on meat and poultry ("Mandatory Safe Handling Statements," 1994). The rationale behind this regulation is found in the following summary statement:

The Food Safety and Inspection Service (FSIS) is amending the Federal meat and poultry products inspection regulations to make safe handling instructions mandatory on all raw meat and poultry product labeling.... The rule provides additional safeguards to protect consumers from exposure to possible bacterial contaminants found in raw meat and poultry products. This action is being taken in an effort to reduce the risk of foodborne illness.

The label is required to include: 1) a rationale statement, 2) a statement that addresses safe storage of raw product, 3) a statement about preventing contamination of kitchen utensils and work surfaces (cross-contamination), 4) a statement about cooking, and 5) a statement about handling leftovers. Specifically, the label reads as follows:

Safe Handling Instructions. This product was prepared from inspected and passed meat and/or poultry. Some food products may contain bacteria that could cause illness if the product is mishandled or cooked improperly For your protection, follow these safe handling instructions. Keep refrigerated or frozen; thaw in refrigerator or microwave; keep raw meat and poultry separate from other foods; wash working surfaces (including cutting boards), utensils, and hands after touching raw meat or poultry; cook thoroughly; keep hot foods hot; and refrigerate leftovers immediately or discard.

FSIS believed that this label would complement and supplement educational programs already in place. The agency argued that the label would serve as an educational tool to more directly reach a large audience, but that it would not take the place of a thorough understanding of safe-handling procedures.

In response to comments about evaluating the effectiveness of this educational tool FSIS stated in the Federal Register notice: "There is no way to quantify the effectiveness of the regulation." Conceivably, this statement was made with respect to evaluating whether the regulation will actually reduce foodborne illness. There is at least one way to indirectly evaluate the regulation, however, and that is to ask people if they have seen the label and if it has changed their food-handling behavior.

College students are at risk for gastrointestinal distress because numerous factors that can contribute to this condition apply to college students, including excessive consumption of alcoholic beverages, stress and anxiety some antibiotics, and food additives (CDC, 1999). According to Eng and AldoBenson (1995), students who drink more than 29 drinks per week are at risk for more health problems than students who drink less than 28 drinks per week. Eng and AldoBenson define health problems as gastrointestinal problems, upper-respiratory problems, and "general malaise ... such as headaches" (p. 734). It appears from their study that students who consume alcoholic beverages in moderation do not experience nearly the number of acute health problems as those who drink excessively

Stress and anxiety disorders can include simple things such as test anxiety and homesickness. More severe disorders-those that may require counseling or therapy and medication-could include generalized anxiety disorder, phobias, post-traumatic stress disorder and others. According to the National Mental Health Association (NMHA) (2001), approximately 60 percent of individuals with depression experience anxiety-related symptoms including irritable-bowel syndrome. NMHA links depression to symptoms that are related to anxiety. A 1999 report of national norms of college freshman states that approximately 38 percent of women and 20 percent of men reported feeling overwhelmed (UCLA, 1999). The study of more than 350,000 freshmen students across the United States is conducted annually and is thought to be the "most comprehensive assessment of student attitudes and plans" (UCLA, p. 2).

There are two reasons that antibiotics may cause diarrhea. The first is that the antibiotic itself may irritate the bowel. The second is that some antibiotics may "kill" the good bacteria in the bowel, which increases the likelihood that a bacterial infection will take over. The bacterial infection then becomes the "cause" of diarrhea (Cleveland, 2002).

According to CDC (2002), food additives such as sorbitol and fructose can also cause acute diarrhea. A small percentage of the population shows a reaction to sulfates that occur in foods such as "baked goods, condiments, (and) snack foods" (FDA, 1992). While some suspect that artificial sweeteners cause diarrhea, this belief is not supported in research (FDA).

Taking all of these factors into consideration, Frenzen et al. (1999) note that diarrhea due to foodborne illness is seriously underreported. The under-reporting is due to a variety of factors, including the fact that "most people with acute diarrhea do not seek medical care" (p. 11). As the results of the present research suggest, it is not uncommon for college students to report having experienced diarrhea. Statistically linking the incidence of diarrhea to food-handling and consumption behaviors is beyond the scope of this study. It is, however, especially important that such research be conducted, since food-handling behavior is a topic that has largely been overlooked in college health and promotion programs. The purpose of the research reported here was to begin an exploration of food-handling behaviors of college students. The baseline data may suggest health intervention programs to promote safe food handling on college campuses before students move into independent living situations.

Methods

The 12 food safety questions from the BRFSS shown in Figure 1 were incorporated into a survey at Ohio University, a 19,000-student state university in southeastern Ohio. FDA developed these questions in 1995 in collaboration with several state health agencies. The purpose of including food safety questions in the BRFSS was to "help characterize persons at high risk for foodborne illness and assist in developing food-safety education strategies for consumers and food handlers that are intended to reduce foodborne illness" (Yang et al., 1998, p. 33). There are several benefits to using the BRFSS questions instead of developing a new survey: 1) the questions have been field-tested and validated, 2) the questions were developed by a panel of experts, and 3) comparisons can be made with previously surveyed populations.

Ohio University's housing policy requires students to live in residence halls for six quarters (two academic years) or until they earn 90 credit hours. There are some exceptions to this rule, but most students do not move into off-campus housing until they are juniors. As students move from dormitories with meal plans, they become responsible for preparing their own meals, many for the first time. Since juniors are the group at Ohio University most likely to have recently become responsible for their own food preparation, they were selected as the population of interest for this research.

The most efficient way to obtain a relatively diverse sample was to target a class that is mainly offered to juniors of all majors. As part of the general-education requirements for graduation at Ohio University undergraduate students must take a junior English class. Students can choose from a variety of classes, but they cannot, with a few exceptions, register for those classes unless they have enough college credits to qualify them as juniors. Students of all majors and backgrounds must take the junior English class, so during any quarter these classes have a diverse mix of students from all majors and a variety of backgrounds.

After Institutional Review Board approval, faculty members who taught all sections of the junior English classes in the fall quarter of 2000 were enlisted to assist with the survey The surveys were distributed in the classes during the last week of the quarter, and students used Scantron scoring sheets to code their responses to the food-handling and demographic questions. A statement on the survey assured students that all responses would remain anonymous. The researchers never saw class lists and have no knowledge of the identity of the students who completed the surveys. Demographic data collected included college rank, age, gender, race, and college enrollment.

The Scantron sheets were read by the computer services testing center at Ohio University, and data were returned to the researchers in electronic form. SPSS version 10.1 was used the compile the data and produce the results for discussion.

Results

Sample

Surveys were completed by 354 students enrolled in junior English classes. The demographic breakdown of survey respondents is given in Table 1. As expected, the majority of respondents were juniors; however, seven students identified themselves as freshmen or sophomores. As stated above, only students with junior standing are eligible to take junior English, but freshman and sophomores can be granted permission by the instructor to take the class under certain circumstances. About one-third of the respondents were seniors; many seniors delay taking their junior English class. While 354 students are not representative of Ohio University students as a whole, the number is adequate to begin some exploratory analysis of food safety behaviors on campus.

Most of the respondents were 18 to 24 years of age, and more respondents were female than male. Ohio University (OU) is a predominately white university so the fact that 92 percent of the students were white was not unexpected. The breakdown of students by college suggests that the distribution in the sample was similar to that in the university as a whole. Figure 2 compares the percentages of respondents in OU's eight colleges with those of university enrollment as a whole. As Figure 2 shows, juniors from the colleges of Education and Business were under-represented. The low number of juniors in University College (UC) is not unexpected, because the majority of students in UC are freshmen and sophomores who have not declared majors.

Food Safety Behaviors

Of the questions asked in the BRFSS, the ones pertaining to consumption of ground beef are the most interesting with respect to this sample. As Figure 3 shows, almost every student (91 percent) reported eating a hamburger in the past 12 months. The consumption of ground beef does not itself produce a risk of foodborne illness; rather the manner in which the hamburger is cooked is the critical element in the safety of ground-beef consumption. Food safety guidelines state that ground beef should be cooked to an internal temperature of 160[degrees]F, and it is safest to consume hamburgers that are not pink or red inside. As Figure 4 shows, almost one-half of the sample (44 percent) reported eating a hamburger in the past 12 months that was pink or red inside. Eating a hamburger that is undercooked is a behavior that could result in foodborne illness.

A cross-tabulation of respondents who ate pink hamburger by gender shows that a substantially higher percentage of males (60 percent) than females (32 percent) reported eating undercooked hamburger. Statistical analysis showed a significant difference in how likely males and females were to eat undercooked hamburgers (Chi square = 31.219; p = .000). The finding that males are more likely to eat undercooked hamburger than females is consistent with earlier findings of the same survey. In the 1995-1996 BRFSS application of the food safety questions, 24.3 percent of the males said they had eaten undercooked hamburger, compared with only 15.6 percent of the females (Yang et al., 1998). The higher percentage found in this study most likely is related to the age group of the respondents.

As noted above, the federal government began an aggressive labeling campaign in 1994 to influence consumers' preparation and handling of raw meat and poultry. These labels are now required on every package of meat and poultry purchased in grocery stores. The labeling has not, however, affected how students prepare their food. More students reported not seeing the label than seeing the lables, and only a small percentage remembered the content of the lables. Most interesting, however, was that the lables had not change the way these students handle and prepare meat and poultry products; as Figure 5 shows, 280 (91 percent) fof the 354 students reported that the new labeling had not changed their food preparation behaviors.

In terms of the incidence of diarrhea, 60 (almost 17 percent) of the 354 respondents reported having diarrhea in the past month. Male students appear to be more likely than females to report diarrhea: 20 percent of the male respondents reported diarrhea, compared with 14 percent of the female respondents. Although foodborne pathogens are common causes of diarrhea, according to Frenzen et al. (1998), laboratories do not routinely test stool samples in cases of diarrhea, and if they do test, they are not looking for foodborne pathogens. This lack of testing was the case at Ohio University. The student health center on campus does not keep records of students with diarrhea, nor does it maintain laboratory records of any stool samples that might have been taken. The bottom line with data pertaining to diarrhea in this research is that many factors contribute to diarrhea among college students, but that we are currently unable to state with any certainty that foodborne pathogens are major contributors.

Comparison with National Sample

The food safety behavior questions were implemented in eight states during 1995 and 1996 BRFSS procedures. An aggregate of the results of the national survey offers some interesting comparisons with this sample of undergraduate students. As Table 2 shows, it is apparent from the comparison that there are some behaviors that put students at greater risk for foodborne illness than members of the general public. The most notable is the fact that only 19.7 percent of the national sample reported consuming undercooked hamburger, whereas 43.5 percent of the local students said they did. The difference in consumption of undercooked hamburger is even more interesting because both the national and local samples included high percentages of people who ate hamburgers during the past year.

Another interesting comparison is found in looking at the impact that the food labeling has had on food preparation. Only 45.4 percent of the national sample and 35.1 percent of the student sample remember seeing the label on meat and poultry. Of those who remembered seeing the label, 77 percent of the national sample remembered reading it and 36.7 percent remembered changing their behavior according to the label's contents. On the other hand, only 26.4 percent of the students remembered reading the label, and only 6.5 percent had changed their food-handling behavior because of it.

Discussion

Food safety and foodborne illness is a serious environmental health challenge that affects all people, possibly causing as many as 76 million illnesses every year in the United States alone (CDC, 2001), with at least one recent outbreak reported in the university setting (Fletcher, Levy, & Griffin, 2000). The 76 million estimated cases include those that are reported, which is a small fraction, and many cases that are not reported. Food safety is a topic in environmental health that is especially salient to universities. When young adults go to college, many of them are forced to become their own cooks for the first time in their lives. This is especially the case when students move out of the dormitory to off-campus housing, as many do in their junior year.

Undergraduate students engage in many behaviors that place their health at risk, including food-handling and consumption behaviors. The risks of alcohol consumption, poor nutrition, and sexually transmitted diseases are the focus of many college health education programs. The results of this study suggest that undergraduate students are placing themselves at risk for foodborne illness.

Hamburgers have become a staple of the American diet, and students consume them frequently. Properly cooked hamburgers pose little short-term health risk, but undercooked hamburgers pose significant short- and long-term health risks. This study suggests that undergraduate students, especially males, are more likely than other members of the population to consume undercooked ground beef. Gender-specific education programs might he needed, targeting male undergraduates. These programs could involve fraternities to promote safe food-handling and consumption behaviors.

The attempt to educate the public about safe food handling by using labels on meat and poultry has not been a successful campaign. Less than one-half of the respondents in the national survey and only about one-third of the students surveyed remembered seeing the labels. The labeling campaign has been even less effective among college students. Students have not read the labels, nor have they changed their food-handling behavior because of the label content. This circumstance suggests that alternative educational approaches are necessary so that students understand the importance of safe handling and preparation.

Students appear to engage in food safety behaviors that place them at greater risk for illness than members of the general population. Although there are strong health education and promotion programs on many campuses, food safety education is generally not emphasized in these programs. The absence of food safety education is important because undergraduates are often responsible for their own diets, including food preparation, for the first time in their lives. Without an understanding of how the food they eat can make them sick, students will continue to suffer from foodborne illness, which may cause their academic pursuits to suffer.

Safe food handling and the risks of foodborne illness should be standard topics in introductory health promotion classes. Educators should consider including food safety in primary- and secondary-school health curricula. Health educators cannot rely on family members to educate their children about safe food handling because our food supply is dynamic and different than it was 20 years ago. In addition, the pathogens that cause foodborne illness are changing and emerging. It was not that long ago that consumption of a rare hamburgers and undercooked eggs was not considered risky behavior by environmental health professionals; today we know that these two behaviors, common in university settings, can lead to serious health effects. The time is ripe to focus the attention of health educators on the important environmental health issue of food safety.

This research explored food safety behavior at one university in Ohio. The results indicate that there is cause for some alarm about our current efforts to educate college students about food safety More research is needed to evaluate the effects of foodborne pathogens on the incidence of diarrhea in college students. Furthermore, educational programs need to be developed to adequately inform students about safe food-handling behaviors. Since college students will become parents and heads of households, teaching them how to keep themselves and their families safe from foodborne pathogens should be an important goal of the college health education curriculum.

[FIGURE 2 OMITTED]

[FIGURE 5 OMITTED]

FIGURE 3

Breakdown of Students Who Reported Eating Hamburgers in the Past 12
Months


Yes         91%
No           8%
Don't know   1%

N = 354.

Note: Table made from pie chart

FIGURE 4

Breakdown of Students Who Reported Eating a Hamburger in the Past 12
Months That Was Pink or Red Inside


Yes            44%
No             49%
Don't know/NA   7%

N = 354.

Note: Table made from pie chart

FIGURE 1

Food Safety Questions in the Behavioral Risk Factor Surveillance Survey

1. After handling raw neat or chicken in the kitchen, which of the following best describes what you usually do next? Do you:

a) continue cooking;

b) rinse and/or wipe your hands then continue cooking;

c) wash your hands with soap and water, then continue cooking;

d) you don't handle uncooked meat or chicken.

2. After you have used a cutting board, counter top, or other surface for cutting raw meat or chicken, which of the following best describes what you usually do next? Do you:

a) continue using the surface as is;

b) rinse and/or wipe the surface, then continue cooking;

c) wash the surface with soap or bleach and water, then continue cooking;

d) you don't cut raw meat or chicken.

3. In the past 12 months, how often did you eat vegetables that you or someone else canned at home, such as asparagus, corn or tomato sauces?

4. In the past 12 months, how often did you eat hamburgers, both at home and away from home?

5. In the past 12 months, how often did you eat hamburgers that were still pink or red on the inside, both at home and away from home?

6. In the past 12 months, how often did you eat eggs that were soft-boiled, soft-poached, loosely scrambled, or lightly fried with a runny yolk, both at home and away from home?

7. In the past 12 months, how often did you eat raw oysters, at home and away from home?

8. In the past 12 months, did you drink any unpasteurized milk, also known as "raw milk"?

9. Since spring of 1994, packages of uncooked meat and poultry at the grocery store have had new labeling information. Meat and poultry labels now include new pictures and written information. Have you seen this information?

10. Do you remember reading anything in the new labeling about safe handling of raw meat and poultry?

11. Has the new labeling information on raw meat and poultry changed the way you prepare these products?

12. In the past month, were you ill with diarrhea lasting at least two days, with at least three loose stools on one of those days?

TABLE 1

Demographics of Sample

Variable    Value Label                 Number of
                                       Respondents

Class rank  Freshman                         2
            Sophomore                        5
            Junior                         236
            Senior                         107
            Other                            4

Age         Under 18
            18-20                          172
            21-24                          168
            25-28                            6
            28+                              6

Gender      Male                           144
            Female                         209

Race        White                          329
            Black                            7
            Asian                            3
            Other                           12

College     Arts & sciences                109
enrollment  Business                         7
            Communication                   82
            Education                       27
            Engineering                     43
            Fine arts                       28
            Health and human services       60
            University college               9

TABLE 2

Comparison of Student Sample to National Sample

Behavior                           National %  Student %

Ate hamburgers during                 86.3       90.4
the past 12 months
Ate pink hamburgers during            19.7       43.5
the past 12 months
Ate runny eggs during the             50.2       50.8
past 12 months
Remembered seeing the label           45.4       35.1
on raw meat and poultry
Remembered reading the label          77.2       26.4
on raw meat and poultry
Changed food preparation behavior     36.7        6.5
because of label information

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Corresponding Author: Michele Morrone, Assistant Professor, Environmental Health Sciences, Ohio University, E325 Grover Center, Athens, OH 45701. E-mail: <[e-mail]>.