Health professionals hold positive attitudes toward biotechnology and genetically engineered foods.

Introduction

Biotechnology is the means by which biological systems or organisms are manipulated to produce a useful product, and many of these processes can directly affect health and nutrition. For example, the engineering of provitamin A into rice endosperm, also known as "golden" rice, provides a means of supplementing vitamin A intake in diets otherwise deficient (Ye et al., 2000). The engineering of a deficient nutrient into a staple foodstuff of a particular culture decreases the costs associated with medical treatment of that nutrient deficiency while the health of the population at large improves. Genetic manipulation also can be used to address nutrition-related disease risks that are associated with consumption of particular nutrients. An example would be the engineering of soybeans high in oleic acid, which are created by suppression of the normal catalytic reaction of oleic acid, a monounsaturated fat, into linoleic acid, a polyunsaturated fat (Kinney, 1996). This process has immense potential to decrease the hydrogenated fat consumption of many Americans, thereby positively affecting the nationwide incidence of cardiovascular disease.

The safety of genetically engineered foods has been determined to be equivalent to that of conventional foods. Furthermore, current evaluation procedures and safety testing have been determined to be sufficient (Dyckman, 2002; Society of Toxicology, 2002). In addition, the Food and Agriculture Organization of the United Nations supports the use of biotechnology in meeting global food productivity needs and recommends a case-by-case scientific evaluation of each genetically engineered food or agricultural item (Food and Agriculture Organization of the United Nations, 2003). Surveys have revealed that consumers have a low confidence level in the government's ability to regulate biotechnology and inform the public about the risks and benefits of this food technology (Hagedorn & Allender-Hagedorn, 1997; Hallman, Adelaja, Shilling, & Lang, 2002). Therefore, they may turn to various health professionals to provide them with clear, understandable, and science-based information about the role of food biotechnology in health promotion and disease prevention.

Several studies have shown that consumers rate physicians and health professionals such as nurses and dietitians as the single most important or valuable source for health information (American Dietetic Association, 2002; McMurchy & Vujicic, 2001; Pennbridge, Moya, & Rodrigues, 1999) and specifically for biotechnology information (Heffernan & Hillers, 2002; Hoban, 1997; Hoban, 2001; Zimmerman, Kendall, Stone, & Hoban, 1994). While no research has been conducted to ascertain nurses' and physicians' knowledge of food biotechnology, research on dietitians has shown these professionals to be somewhat deficient in this area (Dobbins et al., 1994; Sheer & Houston, 2001; Whiting, Berebaum, Pasishnek, Duff, & Anderson, 1997; Wie, Strohbehn, & Hsu, 1998). Increased understanding of food technology, and specifically of biotechnology, is called for by the Commission on Accreditation for Dietetics Education of the American Dietetic Association in the 2002 dietetics education standards (Bruening, Mitchell, & Pfeiffer, 2002).

The purpose of the study reported here was to a) assess the current knowledge, attitudes, and beliefs of dietitians, nurses, and physicians regarding food biotechnology, and b) compare and contrast the resulting data from each group of professionals.

Methods

A three-part questionnaire, adapted from a survey by Wie and colleagues (1998), was used to collect data from registered dietitians (RDs), certified registered nurse practitioners (CRNPs), and physicians including medical doctors (MDs) and doctors of osteopathy (DOs) licensed in the state of Maryland. The self-administered survey included 14 knowledge questions to be answered as true, false, or unsure, and 24 attitude, belief, and awareness questions ranked on a seven-point Likert scale. Demographic data were collected, including each subject's zip code, for the purpose of geographic information systems (GIS) mapping. Additional questions were used to determine each subject's personal use of label reading for GE ingredients and the potential effects of such information on food purchase decisions, sources of biotechnology information, and number of patient inquiries. The survey completion time was assessed at approximately 15 minutes.

A panel of five experts, including a Cooperative Extension specialist, two food biotechnologists, a plant agriculturalist, and a statistician, evaluated content validity. Following revision based on their suggestions, construct validity was assessed via pre-testing and cognitive interviewing of a convenience sample with a size of nine--three subjects from each profession. This phase was designed to reduce response error that might result from misinterpretation of the questions.

Survey reliability was tested through a pilot study, with a convenience sample of 30-10 subjects representing each profession studied. The pilot study received a 47 percent overall response rate. Reliability analysis revealed an alpha of 0.61 for the attitude and belief section and an alpha of 0.74 for the knowledge section.

Data were analyzed by cross-tabulations and descriptive statistics with the graduate package of SPSS[R], Version 11.0. Factor analysis was conducted to determine relationships of attitudes and beliefs. Analysis of variance (ANOVA) was used to test for any differences between and within each group of questions as well as the score on the knowledge section in relationship to each of the demographic variables. Tukey's HSD and Scheffe post hoc tests were applied when appropriate. Statistical significance was defined as p < .05. The protocol for the study was reviewed and approved by the University of Delaware Human Subjects Review Committee.

Results

Demographic Data

A total of 241 responses were received out of the 600 surveys mailed for an overall response rate of 40 percent. As expected, the majority of respondents were female (83 percent, n = 201). RDs had the highest overall response rate, at 47 percent (n = 113). Table 1 summarizes the demographic findings with regard to gender, age, profession, education, religion, and workplace.

Most of the respondents (96 percent, n = 232) had received fewer than 10 patient inquiries over the past year with regard to genetically engineered foods; 69 percent (n = 166) had received no inquiries in the past year.

Subjects were asked about their personal habits of label reading for genetically engineered ingredients. The large majority (71 percent, n = 170) reported either "never" or "rarely" looking for such information. Only 8 percent (n = 19) either "always" or "frequently" read labels for information on genetically engineered food components. When asked what impact such labeling information would have on their purchasing decision, the majority of respondents chose "unsure" (59 percent, n = 143). Twenty-one percent of subjects (n = 50), however, reported that such information would have no impact on their purchasing decisions.

Participants were asked which sources they would use to obtain information about food biotechnology and genetic engineering. The source most commonly reported by all professions was peer-reviewed journals (71 percent). Other sources included continuing-education programs, print media, and broadcast media.

Knowledge Data

Of the 14 knowledge questions, percentage correct scores ranged from a low of 0 (n = 4) to a high of 93 (n = 5). When the unsure response was eliminated, the range decreased--to 7 to 93. Table 2 summarizes the mean-percentage scores and weighted-mean-percentage scores on knowledge questions by profession. The mean percentage correct for the entire group was 55 percent. The weighted-mean percentage correct was 57 percent, which accounts for those who responded "unsure" rather than answered correctly or incorrectly.

Only two of the 14 knowledge questions elicited a high percentage of correct responses: the definition of biotechnology (95 percent) and the question concerning current practical applications of plant genetic engineering (91 percent). The questions that elicited the lowest percentage of correct responses overall were those dealing with the issue of DNA transfer (19 percent) and the Food and Drug Administration (FDA) labeling regulation for genetically engineered foods (27 percent).

Differences in knowledge scores were not significantly related to gender [F(1, 239) = 1.84, p = .18]; age [F(2, 238) = 1.67, p = .19]; religious preference [F(4, 236) = 1.07, p = .37]; level of religious practice [F(3, 237) = 0.685, p = 0.56]; workplace [F(7, 233) = 0.599, p = .76]; or profession [F(2, 238) = 2.65, p = .07]. Those who had been in practice the longest also had the highest knowledge scores, although the difference was not statistically significant [F(7, 233) = 1.39, p = .21]. The higher the level of education, however, the higher the percentage correct on the knowledge section [F(3, 237) = 3.045, p = .03]. Again, the difference was not detected by either of the post hoc tests (Tukey's HSD: p = .08; Scheffe; p = .13).

Attitudes, Beliefs, and Awareness Data

A slight majority (54 percent; n = 129) of subjects reported that they were familiar with biotechnology applications. Attitude and belief statements with the highest and lowest mean ratings are summarized by profession in Table 3. Strongest agreement (89 percent, n = 214) was elicited by the item "I want to know more about biotechnology applications in food and agriculture," followed by 82 percent (n = 198) agreement with "The use of genetic engineering for nonfood purposes such as production of human medicines is an appropriate application." Strongest disagreement (77 percent, n = 185) was elicited by the item "My religious beliefs contribute significantly to my views on food biotechnology and genetic engineering," followed by 72 percent (n = 173) disagreement with "Genetic manipulation of food is unethical and immoral." Two items elicited a strong "no opinion" response. To the item "Biotechnology offers more benefits to farmers than it does to consumers," respondents were decidedly neutral; 41 percent (n = 99) reported having no opinion. Likewise, while 61 percent (n = 146) reported agreement with the statement that "Recombinant DNA technology has resulted in a number of health benefits," 37 percent (n = 89) of subjects selected "no opinion."

Respondents were supportive (63 percent) of the current FDA policy regarding labeling of genetically engineered foods, which requires labeling only when there has been a change in the food's nutritional content or composition, or introduction of an unexpected allergen. The current application of genetic engineering of crops to make them more pest resistant met with 82 percent agreement. The majority of subjects (54 percent) reported that they were not comfortable with their ability to discuss the science of genetic engineering with their clients. This percentage was the same as that of subjects who also disagreed that current government regulations on food biotechnology are sufficient.

Views on the future impact of genetic engineering on health were elicited. Respondents indicated general agreement that food biotechnology has the potential to positively affect human health over the next 20 years (55 percent) and that genetically engineered "functional foods" would aid in the process of disease risk reduction (51 percent). It is notable, however, that both questions elicited a substantial "no opinion" response (28 percent for each).

Factor Analysis

A factor analysis was done to identify and summarize the potential interrelationships that exist among a larger set of individual variables. A three-factor solution was the most interpretable. Factor 1, genetic engineering, was related to the appropriateness of a specific biotechnology or genetic-engineering application as well as the ethics and morality of genetic engineering. Factor 2, research, focused on the possible benefits of biotechnology research. Factor 3, policy, included the role of the health care professional in relaying information to the public about biotechnology and policy issues.

Gender was negatively correlated to Factor 1, genetic engineering. Females tended to have a more negative attitude toward specific biotechnology applications than males [t(1, 239) = -3.35, p = .001]. Profession was positively correlated with both attitudes toward the genetic-engineering factor and Factor 2, policy. Physicians tended to have a more positive attitude toward the application of specific genetic-engineering applications than either NPs or RDs [F(2, 238) = 6.9, p = .001].

Education was found to be positively related to attitudes toward the genetic-engineering group. The higher the level of education received by subjects, the more they tended to view specific biotechnology applications positively [F(3, 237) = 6.38, p = .000].

Limitations

One limitation of the study is the utilization of licensed professionals in Maryland. The use of this sample poses implications for generalizability to other regions of the nation. Second, there may be a female gender bias as a greater number of subjects responding were female. Nonresponse bias is a limitation because of the potential for those who choose to respond to have different characteristics than those who do not respond. The greatest potential for this bias exists with respect to physician participation, who historically have limited participation in survey research (Dillman, 2000). In addition, health care professionals in busy office or clinic settings often have their mail opened and screened by office staff. These "gatekeepers" may have contributed to or diminished the response rate of the survey.

Applications and Conclusions

Current research reveals innumerable ways in which biotechnology can affect food, food safety, nutrition, and health (Comai, 1993; DellaPenna, 1999; Fogg-Johnson & Merolli, 2001; Harlander, 2002). Surveys conducted with consumers as well as targeted professional groups have shown an overall lack of knowledge regarding applications of food biotechnology (Frewer, Shepherd, & Sparks, 1994; Heffernan & Hillers, 2002; Hoban, 1997; Hoban, 2001; Lusk & Sullivan, 2002; Zimmerman et al. 1994). Research conducted specifically with RDs similarly reveals a lack of knowledge within this group of health professionals (Dobbins et al., 1994; Sheer & Houston, 2001; Whiting et al., 1997; Wie et al., 1998). Despite this lack of knowledge, these same studies show that both consumer groups as well as dietitians have a positive attitude overall toward food biotechnology.

The investigation reported here into the knowledge, attitudes, and beliefs of nurse practitioners, physicians, and dietitians, confirms the findings of those previous researchers in that this sample also demonstrated a positive attitude toward the benefits, health, and safety of food biotechnology despite low overall knowledge of the subject. Professional comparison reveals that no group of health professionals was significantly more knowledgeable on the topic of food biotechnology. Physicians, however, displayed more positive attitudes toward specific biotechnology applications such as applications for human medicines, nutritional content improvement, and improving plant resistance to pests.

None of the health professionals felt that religion was an influence on their views, nor did they view genetic engineering as illegal or immoral. None felt that their patients were overly concerned about genetically engineered foods. Only physicians felt comfortable discussing the science of genetic engineering with their patients. All supported FDA labeling rules for genetically modified foods and agreed that health will improve as a result of biotechnology applications.

Consistent with the findings of prior research (Wie et al., 1998) and despite ongoing development and media attention given to genetic-engineering advancements, RDs in the study were no more knowledgeable than those in prior studies. Physicians and nurse practitioners showed similar low levels of knowledge.

Although knowledge about food biotechnology is low among health professionals, this circumstance has not diminished their expectation that biotechnology potentially offers health benefits. This finding is not unlike that of Frewer and co-authors (1994), who found that lack of understanding about biotechnology does not inhibit the formation of attitudes toward it. What has yet to be determined is whether this positive-benefit expectation will influence the attitudes, beliefs, and purchasing decisions of health professionals and whether it will have any impact on their clients' attitudes.

Biotechnology has the potential to positively affect human health. Health professionals can either facilitate or diminish this process, according to their level of understanding about the technology and their ability to communicate it effectively. The study reported here showed the need for further biotechnology education among a variety of health professionals. This point is highlighted most appropriately by a comment from a nurse practitioner, who stated. "If we conclude that knowledge of [biotechnology] has clinical relevance, we are bound to become competent enough to offer intelligent advice to our patients." Consumers who rely on these professionals for trusted, unbiased opinions will subsequently adopt or reject the technology. In order to deal with client questions, health professionals need to become more knowledgeable in communicating biotechnology information to consumers. Given that health professionals rely most on peer-reviewed journals and continuing-education programs as their sources of information on this topic, emphasis should be placed on increasing communication via these routes.

TABLE 1 Demographic Data on Respondents

Characteristic         n    Mean Percentage

Gender
  Female               201  83.4
  Male                  40  16.6
Age
  45-64                126  52.3
  25-44                105  43.6
  65+                   10   4.1
Profession
  RD                   113  46.9
  CRNP                  85  35.3
  MD                    43  17.8
Education
  Master's             125  51.9
  Bachelor's            63  26.1
  Medical               39  16.2
  Doctorate             14   5.8
Religious preference
  Protestant            88  36.5
  Catholic              72  29.9
  Jewish                28  11.6
  Other                 28  11.6
  None                  25  10.4
Work site
  Private practice      62  25.7
  Other                 50  20.7
  Acute care            39  16.2
  Long-term care        30  12.4
  School/university     28  11.6
  Public health         19   7.9
  HMO                   10   4.1
  Home health            3   1.2

TABLE 2 Percentage of Correct Answers on Knowledge Test, by Profession

                                               Weighted Percentage
Profession            Mean Percentage Correct  Correct*

CRNP
  Mean                 52.26                    54.85
  N                    85                       81
  Standard deviation   19.69                    16.24
MD
  Mean                 60.47                    60.47
  N                    43                       43
  Standard deviation   15.69                    15.69
RD
  Mean                 55.69                    56.18
  N                   113                      112
  Standard deviation   19.93                    19.31

*Weighted score accounts for subjects who answered "unsure" rather than
correctly or incorrectly.

TABLE 3 Attitude and Belief Ratings* by Licensed Health Professionals**

Items of Strongest Agreement      All Professions     NP**

I want to know more about         2.18 [+ or -] 1.17  2.25 [+ or -] 1.13
  biotechnology applications in
  food and agriculture.
The use of food biotechnology to  2.53 [+ or -] 1.17  2.59 [+ or -] 1.07
  modify a plants' genetic
  structure to be more protected
  from damage by insects is an
  appropriate application.
The use of genetic engineering    2.58 [+ or -] 1.30  2.62 [+ or -] 1.24
  for nonfood purposes such as
  production of human medicines
  is an appropriate application.
Using biotech varieties of        2.61 [+ or -] 1.28  2.68 [+ or -] 1.28
  traditional food crops to
  produce human medicine is an
  appropriate application.
Recombinant DNA technology has    2.88 [+ or -] 1.88  3.02 [+ or -] 1.11
  resulted in a number of health
  benefits.
More research needs to be done    2.95 [+ or -] 1.54  2.59 [+ or -] 1.37
  before genetically engineered
  foods are available for
  consumer use.

Items of Strongest Disagreement

My religious beliefs contribute   5.73 [+ or -] 1.56  5.69 [+ or -] 1.39
  significantly to my view on
  food biotechnology and genetic
  engineering.
Genetic manipulation of food is   5.32 [+ or -] 1.49  5.20 [+ or -] 1.56
  unethical and immoral.
The genetic engineering of        5.19 [+ or -] 1.39  5.04 [+ or -] 1.19
  plants should be prohibited.
I am comfortable discussing the   4.59 [+ or -] 1.67  5.09 [+ or -] 1.66
  science of genetic engineering
  with patients in my practice.
My patients are concerned about   4.58 [+ or -] 1.63  4.82 [+ or -] 1.58
  genetically engineered foods.
The genetic engineering of        4.27 [+ or -] 1.81  3.96 [+ or -] 1.75
  animals to improve their value
  to consumers should be
  prohibited.

Items of Strongest Agreement      MD**                RD**

I want to know more about         2.30 [+ or -] 1.14  2.09 [+ or -] 1.14
  biotechnology applications in
  food and agriculture.
The use of food biotechnology to  2.42 [+ or -] 1.2   2.52 [+ or -] 1.23
  modify a plants' genetic
  structure to be more protected
  from damage by insects is an
  appropriate application.
The use of genetic engineering    2.16 [+ or -] 1.48  2.71 [+ or -] 1.25
  for nonfood purposes such as
  production of human medicines
  is an appropriate application.
Using biotech varieties of        2.09 [+ or -] 1.25  2.75 [+ or -] 1.26
  traditional food crops to
  produce human medicine is an
  appropriate application.
Recombinant DNA technology has    2.19 [+ or -] 1.31  3.04 [+ or -] 1.09
  resulted in a number of health
  benefits.
More research needs to be done    3.59 [+ or -] 1.55  2.97 [+ or -] 1.60
  before genetically engineered
  foods are available for
  consumer use.

Items of Strongest Disagreement

My religious beliefs contribute   6.05 [+ or -] 1.68  5.64 [+ or -] 1.64
  significantly to my view on
  food biotechnology and genetic
  engineering.
Genetic manipulation of food is   5.84 [+ or -] 1.62  5.20 [+ or -] 1.47
  unethical and immoral.
The genetic engineering of        5.79 [+ or -] 1.46  5.07 [+ or -] 1.45
  plants should be prohibited.
I am comfortable discussing the   3.77 [+ or -] 1.66  4.52 [+ or -] 1.63
  science of genetic engineering
  with patients in my practice.
My patients are concerned about   4.51 [+ or -] 1.53  4.42 [+ or -] 1.69
  genetically engineered foods.
The genetic engineering of        5.35 [+ or -] 1.73  4.08 [+ or -] 1.74
  animals to improve their value
  to consumers should be
  prohibited.

* Mean rating [+ or -] standard deviation based on a seven-point Likert
scale, where 1 = strongly agree and 7 = strongly disagree.
** Certified registered nurse practitioners (NPs), N = 85; physicians
(MDs), N = 43; registered dietitians (RDs), N = 113.

Acknowledgements: The authors acknowledge the International Food Information Council for providing the research funding to conduct this study and Drs. Cathy Hsu, Catherine Strohbehn, and Seung Hee Wie, who granted the authors permission to adapt and utilize the survey instrument (Wie, Strohbehn, & Hsu, 1998).

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Jennifer Schmidt, M.S., R.D.

Connie E. Vickery, Ph.D., R.D., F.A.D.A.

Nancy A. Cotugna, Dr.PH., R.D.

O. Sue Snider, Ph.D.

Corresponding Author: Jennifer Schmidt, Educational Consultant, Maryland Agricultural Education Foundation, 1011 Sudlersville Cemetery Rd., Sudlersville, MD 21668. E-mail: [e-mail].