Assessing Knowledge and Attitudes of U.S. Healthcare Providers about Benefits and Risks of Consuming Seafood
An online needs assessment survey of healthcare providers was developed and implemented to determine knowledge and attitudes about the benefits and risks of consuming seafood along with how this might impact patient/clientele counseling. Only 6 of the 45 knowledge items queried (13%) met the 80% subject mastery or proficiency with a total knowledge score of 56 ± 18%. Based on this survey, it was found that healthcare providers were less than proficient regarding all knowledge areas for seafood. Understanding of seafood safety and contaminants was low. In addition, while the majority (76%) of healthcare respondents knew the correct recommendation for seafood meals per week, they failed to identify the groups that were targeted by the Food and Drug Administration/Environmental Protection Agency (FDA/EPA) advisory about seafood and mercury and therefore could be providing inaccurate information. Attitudinal responses for 18 items resulted in an overall average score of 3.28 ± 0.47 meaning slightly agree (based on a 5-point Likert scale strongly disagree—strongly agree). While trends showed that it was important to the respondents to provide accurate information (3.78 ± 1.06) about seafood to their patients, they felt more comfortable recommending that their patients follow government advice (3.52 ± 0.91) about both seafood safety and which seafood to eat over other sources. Combined with a low knowledge base, attitudinal responses indicate that there could be a barrier to both outreach education to these healthcare providers and to their patient counseling regarding seafood consumption. Results also showed that a combination of online, science-based, easy to access information with the capability to provide brochure-formatted information would appear to be the best way to communicate seafood safety, nutrition, and health information.
Seafood is a major food commodity worldwide. Seafood, for the purposes of this paper, is defined as all marine and freshwater finfish (i.e., tuna, shark, and flounder) crustaceans (i.e., shrimp and crabs), mollusks (i.e., clams, oysters, and mussels), and other forms of aquatic life (including squid, sea turtle, jellyfish, sea cucumber, sea urchin, and the roe of such animals) other than birds or mammals, harvested for human consumption as delineated by the FDA in the Seafood Hazard Analysis Critical Control Point (HACCP) regulation (Title 21 part 123, Section 123.3). Seafood can be wild or farm-raised, processed (i.e., canned, frozen, smoked, pickled, and breaded) self-caught, or fresh from a market or restaurant. At U.S. ports alone, commercial fisheries had a landed value of $4.5 billion in 2010 reflecting 8.2 billion pounds (NMFS 2012). Since seafood is a primary source of high-quality protein and a variety of nutrients needed for overall health, it is paramount to inform the general public of consumer health risks and benefits. Publications, ranging from medical journals to news articles, report the extensive health and nutritional benefits of seafood, while others warn against toxic effects. Numerous studies have confirmed the positive impact of seafood consumption for reduction of coronary heart disease (He and others 2004; Mozaffarian and others 2005; Iso and others 2006), supporting cognitive development and vision (Colombo and others 2004; Daniels and others 2004; Innis 2003), and other potential benefits such as the reduction of Attention deficit-hyperactivity disorder symptoms (Richardson and Montgomery 2005; Bloch and Qawasmi 2011) and depression (Hibbeln 1998). However, research has demonstrated that there is much confusion among consumers about risk/benefits of seafood consumption since recommendations have been fragmented and conflicting. Determination of risk/benefit is complex and requires better strategies based on accurate information to provide guidance to consumers (National Academy of Sciences 2006).
Communicating the net benefits of seafood consumption can be difficult. The media have been identified by consumers as a major source of seafood-related information (Hicks and others 2008). However, media often provide confounding and sometimes incomplete information. The bulk of seafood consumption messages have been focused on risks; messages related to benefits may get lost to consumers, with risk messages outweighing benefit messages by 4:1 over a 15-year period (Greiner and others 2010). Seafood is the most important dietary source of the omega-3 fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), required for brain development, heart health, and optimal fetal development. Unfortunately, misinterpretations of risk advisories, for example, methylmercury, have resulted in an overall reduction in seafood consumption by at-risk groups, rather than an increased ability to balance risk and benefits (Oken and others 2003; Harris and others 2009). Public health practitioners need to work with the media to more effectively communicate both benefits and risks concerning fish consumption (Greiner and others 2010). An increase in the overall effectiveness and accuracy of seafood risk/benefit information to consumers may be accomplished by targeting specific intermediaries, such as healthcare providers/practitioners (National Academy of Sciences 2006).
Studies have shown that consumers consider physicians and other health professionals (e.g., nurses and dietitians) valuable sources of health information (Schmidt and others 2005) and they are considered as a trusted source for information during pregnancy and routine medical visits (Morales and others 2004; Cody and others 2012). Health professionals equipped with evidence-based educational materials and information could convey accurate and concise explanations to clientele (Delgado-Guterrez and Bruhn 2008). However, anecdotal information has suggested that healthcare providers may not be conveying accurate or current information to their patients regarding the relative benefits and risks of seafood in areas such as general safe handling of seafood, seafood contaminants, and health and nutrition. Little is known about what healthcare providers are telling patients about seafood, particularly pregnant/nursing mothers. Therefore, the overall goal of research was to develop and implement a national needs assessment survey of healthcare providers/practitioners that would ascertain the knowledge and attitudes of the medical community regarding seafood safety issues and the benefits and risks of seafood consumption. This needs assessment survey addressed 5 key areas: (1) demographics, (2) knowledge and attitudes regarding seafood safety/nutrition, (3) Contaminants, and (4) safe handling as well as (5) preferred sources of information/training for themselves and their clientele. Ultimately, this information could be used to generate outreach resources for members of the medical community to use with their patients.
Methods and Materials
Sampling and data collection
A needs assessment survey of healthcare providers was developed and implemented using 2 online services: Qualtrics™ (www.qualtrics.com) and Zoomerang™ (www.zoomerang.com) launched in the fall 2008 and spring 2009, respectively. Initially Qualtrics™ was used when the project directors attempted to target listserves and e-mail lists for specific healthcare professionals. However, this protocol did not provide an adequate response rate. In an effort to maximize response from healthcare providers, the project directors administered the survey using a Zoomerang™ standing healthcare professional panel (Hicks and others 2008, 2009) since Qualtrics™ was cost-prohibitive. Results of the 2 survey tools were merged and analyzed as 1 database. After consultation with an expert evaluator, it was agreed that combining the results from the survey was permissible. It would be no different than sending out the same mail survey twice.
The survey consisted of 5 sections: demographics, patient/client description, knowledge questions about seafood, attitudes about seafood nutrition and food safety and scientific evidence, and sources of information and training. Respondents were asked to check all that applied for specific questions that had, potentially, more than 1 answer. The knowledge questions were divided into 3 content categories: seafood safety/contaminants, seafood health/nutrition, and general food safety. The response for these questions was disagree, agree, or don't know. Knowledge-based questions were graded as right or wrong. For purposes of statistical assessment, “not sure” was considered a wrong answer. Subject mastery, at 80% correct, was used as previously determined by food safety experts (Pivarnik and others 2006, Pivarnik and others 2012). Attitude statements were rated on a 5-point Likert scale with 1 = strongly disagree, 2 = agree, 3 = neither agree nor disagree, 4 = agree, and 5 = strongly agree.
The protocol and questionnaire were approved by the Univ. of Delaware Institutional Subjects Review Board (IRB no. XMP285). Prior to the implementation, the survey was reviewed for content validity and clarity by 13 seafood safety and health experts from academia, health, and medical professions. In addition, the instrument was pilot tested by 19 representatives of the target audience to access readability and assist in the examination of content reliability. All suggestions were considered and the questionnaire was revised based on these recommendations.
Descriptive statistics, such as frequencies, distributions, percent, and standard deviations and cross tabulations, were computed. Data analysis was carried out using the Statistical Product and Service Solutions (SPSS, version 16.0, Chicago, Ill., U.S.A.). One-way analysis of variance followed by the Scheffe posthoc procedure, t-tests, and/or chi-square statistics were performed to determine statistical differences. Item means were rank ordered. Reliability was examined using Cronbach's alpha measure of internal consistency. Knowledge and attitude questions were correlated with demographic variables. Significant findings were reported at the P < 0.05 level.
Results and Discussion
Most survey questions were completed by 641 to 647 respondents. However, respondent frequencies varied and are specified for clarification where appropriate and statistical assessment of key variables did not use partial survey responses. Table 1 and 2 show the demographic characteristics of the healthcare provider respondents. Of those surveyed, 83% were female, 78% were between 35 and 64 years old, 43% have been practicing 15 years or less, and 90% saw up to 30 patients/day. Respondents were equally distributed throughout the regions of the United States. Table 2 illustrated the top 5 MD/DO (Medical Doctor/Doctor of Osteopathy) specialties identified by respondents. The other 3 healthcare specialties show that the majority (62%) of respondents held healthcare credentials that have been categorized as traditionally female and this accounts for the high female response rate. A previous survey of health professionals regarding food processing technologies (Delgado-Gutierrez and Bruhn 2008) also had a high female respondent rate (88%).
Table 1. Demographic characteristics of healthcare survey respondents
|Gender (N = 652)|| || |
|Age distribution (N = 652)|| || |
|< 35 years old||96||14|
|35 to 54 years old||326||50|
|55 to 64 years old||181||28|
|≥65 years old||49||8|
|Region of the country (N = 651)|| || |
|Length of practice (N = 650)|| || |
|≤ 15 years||275||43|
|16 to 25 years||140||21|
|Number of patients/clients/day (N = 593)|| || |
|31 to 50||36||6|
|Talk about nutrition with patients (N = 603)|| || |
|Confidence providing nutrition advice (N = 647)|| || |
|Seafood* consumption frequency (N = 596/647 eat seafood)|| || |
|1 to 3 times/month||221||37|
Table 2. Profile of the top 4 healthcare credentials and/or specialties (N = 531)
|Top 5 specialties*|| || |
|General/family practice|| || |
|Pediatrics|| || |
|Internal medicine|| || |
|Emergency care|| || |
|OB/GYN|| || |
|Nurse practitioner/physician's assistant||26||4|
Tables 3 and 4 illustrate the rank ordering of the knowledge questions from low to high by mean and content mean category scores, respectively. Total knowledge had an alpha reliability of 0.89 indicating that the data were reliable for knowledge measures. The questions were grouped into the content areas of seafood contaminants, health and nutrition, and seafood safety. The bolded scores in the table indicate the percent correct answer for each knowledge item. Only 6 of the 45 knowledge items queried (13%) met the 80% subject mastery or proficiency with a total knowledge score of 56 ± 18%. The mean percent correct scores ranged from 38% to 69% for the different content categories; furthermore, 76% to 100% of the questions were below mastery in these categories. There were no differences in knowledge with gender or length of practice. While there were some slight differences between some regions of the country, these were not considered important because all the groups did so poorly. In a small study of healthcare providers for pregnant women, Morales and others (2004) found that doctors and midwives were less interested in learning about food safety than other professional health groups and had limited understanding of issues. Healthcare services did not provide these women with adequate information about foods that deliver high amounts of omega-3 fatty acids, for example, seafood (Sinikovic and others 2008). This may be due to the overall lack of seafood safety, and seafood health and nutrition knowledge in the medical community.
Table 3. Survey knowledge question responses in ranked order within safety categories from high to low by correct answers. (N = 641)
|Farm-raised salmon is safe for your patients to eat.||67||10||23|
|Men and nonchild bearing aged females should not eat swordfish.||6||61||33|
|It is safe for pregnant and nursing women to eat seafood.||52||23||25|
|Pregnant and nursing women and women of childbearing age are advised to eat up to 2 servings of low mercury seafood per week.||49||21||30|
|Salmon is high in mercury.||11||47||42|
|Farm-raised Atlantic salmon is not safe to eat due to the high levels of environmental contaminants.||11||43||46|
|Proper trimming of recreationally caught fish can reduce the level of certain contaminants.||42||16||42|
|Women of child bearing age should not eat flounder.||8||41||51|
|Every state posts fish consumption advisories about locally caught fish.||39||15||46|
|Shark, swordfish, tilefish, king mackerel, and canned tuna are the only seafood listed in the FDA/EPA Advisory.||18||27||55|
|Fresh tuna is included in the FDA/EPA Advisory about mercury in seafood.||48||11||41|
|There are no documented cases of mercury poisoning due to eating seafood in the United States.||10||41||49|
|The FDA (Food and Drug Administration)/EPA (Environmental Protection Agency) Advisory about mercury in seafood provides specific guidance for the general population.||69||3||22|
|Seafood health and nutrition (17 items)|
|Seafood is an excellent source of high-quality protein.||91||3||6|
|Deep-fat frying is a healthy way to prepare seafood.||3||90||7|
|Eating fish can decrease the risk for cardiovascular disease.||89||2||9|
|Fatty fishes, like mackerel and salmon, are a good source of omega-3 fatty acids.||87||3||10|
|All seafood is high in cholesterol.||4||79||17|
|It is recommended that consumers eat seafood twice a week.||76||7||17|
|Seafood is high in saturated fat.||5||73||22|
|Eating seafood is the best way to obtain omega-3 fatty acids in a diet.||72||9||19|
|The proteins in seafood are harder to digest than the proteins in red meat or poultry.||4||71||25|
|Farm raised fish can be a good source of omega-3 fatty acids.||69||10||21|
|The proteins in seafood contain all the essential amino acids needed for growth and maintenance.||67||10||23|
|DHA found in fish oils is important for the central nervous system development of the fetus and infant.||63|| || |
|Seafood is low in sodium.||60||14||26|
|EPA and DHA are the 2 important omega-3 fatty acids found in seafood.||60||3||37|
|Including fish-based omega-3 fatty acids in the diet can protect against diabetes.||53||13||34|
|Clams and oysters are good sources of iron.||41||11||48|
|Alpha-linolenic acid (ALA) (plant based omega-3 fatty acids found in flax and walnuts) is equivalent in nutritional value to DHA.||24||23||53|
|Seafood general food safety (15 items)|
|It is safe to put cooked fish back on the same unwashed plate used for the uncooked fish.||2||91||7|
|Raw or lightly cooked seafoods are safe for immune-compromised people.||5||80||15|
|Raw oysters and clams are safe for all of your clients and/or patients to eat.||5||79||16|
|Some disease causing bacteria can grow at refrigerator temperatures.||77||7||16|
|Frozen fish can be thawed on the counter top.||14||74||12|
|Home refrigerators should be maintained at 41 °F or below.||73||9||18|
|The safety of fish can be determined by smell.||11||70||19|
|Seafood that has been handled and/or prepared properly can be kept in the freezer for 6 months and still is safe to eat.||65||11||24|
|Hand sanitizers are the best way to wash your hands after handling seafood.||18||64||18|
|Allergens and disease-causing bacteria are the biggest food safety issues associated with seafood.||56||21||23|
|Organic-labeled seafood would be safer than wild caught seafood of the same species.||15||42||43|
|Cold smoked seafood products are safe for pregnant women.||13||40||47|
|Seafood should be cooked to an internal temperature of 145 °F for 15 s.||31||16||53|
|Farm-raised salmon contains artificial coloring.||27||24||49|
|Steaming clams until they open results in a fully cooked product.||45||19||36|
Table 4. Mean (%) knowledge scores for healthcare providers in content categories (N = 641)
|Seafood/health nutrition||69 ± 22||23 to 91||76.5%||17|
|General food safety (seafood)||59 ± 20||17 to 70||86.7%||15|
|Seafood safety/contaminants||38 ± 21||9 to 67||100%||13|
|Total knowledge||56 ± 18||9 to 91||87%||46|
Table 5 shows a comparison of percent knowledge scores about seafood in the 3 content categories by specific healthcare provider groups that accounted for 78% of respondents. Total knowledge scores for all the groups were below mastery; however, RD/Nutritionists did significantly (P < 0.05) better than MD/DO and RN/LPN (licensed practical nurse)/nurse midwife in both total and content category knowledge. Food safety knowledge of RDs was studied by Medeiros and Buffer (2012) and they found that knowledge scores were also less than proficient, ranging between 50% and 75%. As could be expected, the RD/nutritionist group was proficient in the category of seafood health and nutrition. While respondents (65%) felt comfortable providing nutritional advice to their clientele (Table 1), overall, the healthcare providers surveyed were below proficiency in the area of seafood health and nutrition. Similar results were found by Buffer and others (2012) regarding issues relating to food safety. These researchers determined that both RDs and RNs had gaps in knowledge and understanding of Listeria monocytogenes; however, RDs were more knowledgeable than RNs about the pathogen and its food safety implications. Therefore, neither group consistently provided prevention information to their patients and needed resources and training. With 15% to 20% of the global population in developed countries, like the United States, showing greater susceptibility to foodborne illnesses (e.g., pregnant women, elderly, infants, chronically ill, and immunosuppressed), clear advice about food safety and safe nutritious foods is very important (Lund and O'Brien 2011). A recent web-enabled food safety survey indicated that consumers would be willing to change food handling practices if prompted, by health professionals (Cody and others 2012). However, with such a low knowledge base about seafood nutrition, safety, and health, the medical community would not be able to provide the consistent and accurate seafood-related information needed by patients/clientele that would enable them to make educated decisions about seafood consumption.
Table 5. Percent (%) knowledge scores about seafood by specific healthcare provider groups in content categories
|General food safety (seafood)||71a||59b||58b|
Attitudinal responses resulted in an overall score of 3.28 ± 0.47 with an alpha reliability = 0.86 (data not shown). There were 18 questions reflecting 2 areas. The first attitudinal category (6 questions) probed how the respondents felt about whether the strength of scientific evidence regarding the impact of seafood consumption on human health was convincing (3.40 ± 0.47). The highest scores reflected confidence in the role of fish or omega-3 consumption in both reduced cardiac death (3.73 ± 0.79) and impact on brain neural development in pregnancy/infancy (3.66 ± 0.84). The score was high as well for detrimental mercury impact on brain neural development during pregnancy/infancy (3.64 ± 0.86). The 2nd category contained 12 questions regarding beliefs about seafood nutrition and food safety (3.22 ± 0.63). Trends showed that it was important to the respondents to provide accurate information (3.78 ± 1.06) about seafood to their patients. They felt more comfortable recommending that their patients follow government advice (3.52 ± 0.91) about seafood safety and which seafood to eat rather than recommendations from: consumer advocacy groups (3.25 ± 0.85); university professionals (3.17 ± 0.85); environmental groups (3.04 ± 0.87); seafood industry and trade associations (2.96 ± 0.82); the media (2.82 ± 0.91); and themselves (2.80 ± 0.94). Other researchers have also found that consumers still find the government as the most trusted source of food safety information (Hicks and others 2008; Cody and others 2012). In an Internet-based survey of physicians, Bleich and others (2013) found that beliefs about diet-related obesity could translate to the kind of counseling topics that physicians dispensed to their patients. Overall, the healthcare providers surveyed did not have a strong positive attitude, and thus they could be ambivalent about communicating about the importance of seafood benefits and risks to their patients. Attitudes and poor knowledge base could be a barrier to both outreach education to this group and to their patient counseling regarding seafood consumption.
Table 6 illustrates how aware and knowledgeable the healthcare provider respondents were of the 2004 Food and Drug Administration/Environmental Protection Agency (FDA/EPA) joint advisory about mercury in seafood (http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2004/ucm108267.htm). Healthcare providers who indicated they were not knowledgeable (81%) were directed to read the advisory, online, prior to answering knowledge-based questions about the advisory. Of these respondents, only 29% were able to correctly identify the target population for the advisory. For the healthcare providers who were knowledgeable and not directed to read the advisory online prior to answering the knowledge-based questions, only 16% were able to correctly identify the target audience. Overall, only 27% of respondents, even with access to the advisory, could correctly identify the target populations: women of childbearing age, pregnant or nursing mothers, and young children. However, the results appear to show that healthcare providers who indicated that they were knowledgeable were clearly not and that the advisory language, even if read, still did not appear to help clarify the advice. Yet, a high majority of respondents (total 87%) could correctly identify the frequency of seafood consumption recommended by the advisory (2 meals per week). However, there was some impact to reading the advisory; those reading the advisory did better with identifying the target audience and to a greater number also had a significantly greater response to correctly identifying the number of meals recommended.
Table 6. Healthcare provider knowledge about FDA/EPA advisory about mercury in seafood (N = 642)
|Aware/not aware not knowledgeable||519||81||Yes||29 (N = 151)||89|
|Aware knowledgeable/very knowledgeable||123||19||No||16 (N = 19)||75|
|Total respondents||642||100||=====||27 (N=170)||87 (N = 559)|
Current and preferred sources of information and training for healthcare providers, and preferred ways to distribute information to patients are presented in Table 7 and 8, respectively. While the Internet and online formats appeared in the top 4 choices for both healthcare information/training, and patient/clientele information distribution, printed materials such as journals, newsletters, brochures, and factsheets were still preferred over Internet sources. While other researchers of health professionals have found that the Internet topped the list for information sources, printed materials such as journals and technical reports were still in the top 3 (Delgado-Guierrez and Bruhn 2008; Medeiros and Buffer 2012). However, leaflets or brochures have been found to be important to meet information needs of health professionals and their patients/clientele (Delgado-Guierrez and Bruhn 2008; McClinchy and others 2011). Furthermore, Delgado-Guierrez and Bruhn (2008) found that the likelihood of communicating information to their patients, in this case about food produced by new processing technologies, increased as they became informed through informational brochures. Preferred resource formats were consistent with all patient/client descriptions: age, income gender, ethnicity, and community. Therefore, a combination of online, science-based, easy to access information with the capability to provide brochure-formatted information would appear to be the best way to communicate seafood safety, nutrition, and health information. However, when the respondents were asked in a yes/no/not sure question about their willingness to use seafood-related materials for their patients that were developed by, or in association with an organization outside of the healthcare (or medical) system, only 58% said yes and 42% indicted they would not or were undecided. This could be a challenge to encourage healthcare providers to use information about seafood provided by university programs such as Sea Grant or Cooperative Extension.
Table 7. Current sources of training and information for the healthcare community
|Brochures, pamphlets, or fact sheets||376||57|
|Quick reference guides||298||46|
|Web-based training/online course||249||38|
|Seminars/workshops attached to conferences||177||27|
Table 8. Respondents preferred way to dispense information to patients/clientele concerning seafood health benefits/risks (checked all that applied)
|Fact sheets developed by medical community||375||57|
|Fact sheets developed by the government||364||56|
|Referral to other health professional||232||35|
|Referred Internet sites||166||25|
|Consultation with you||155||24|
|Fact sheets developed in-house||148||23|
|Consultation with other staff||129||20|
|Popular health magazines||67||10|
|Referral to community clinic||31||9|
|Referral to pharmacist||9||1|
Based on this survey, we found that healthcare providers were less proficient regarding all knowledge areas for seafood. Understanding of general seafood safety and seafood contaminants was low. While knowledge about seafood health and nutrition was the best, the majority of respondents were not proficient. This lack of knowledge would impact the overall health and nutrition advice and/or information dispensed to patients. While the majority of respondents knew the correct seafood consumption advice, they failed to identify the groups that were targeted by the FDA/EPA advisory about seafood and mercury, and therefore could be providing inaccurate information. Therefore, healthcare providers need accurate information about seafood and health. Based on insight into the preferred formats for information and training for healthcare providers and their patients, a research-based website was developed that provides balanced information about the benefits and risks of seafood. This website was not specifically developed as a result of the survey but the survey results aided the design and format. Seafood Health Facts: Making Smart Choices (www.seafoodhealthfacts.org) has been designed to provide all information in a downloadable format and includes brochures, factsheets, and reference guides. Potential keys to improving healthcare providers’ knowledge about the health benefits of including seafood in the diet and relaying accurate information to their clientele include continuing to promote the website with these groups and updating and refining the website.
This research was supported by USDA/CSREES Award no. 2007-51110-03815. In addition Natl. Fisheries Inst., Fisheries Scholarship Fund contributed to the project.