Self-Reported Changes in Food Safety Behaviors among Foodservice Employees: Impact of a Retail Food Safety Education Program
ABSTRACT: A food safety education program developed for retail food establishments was evaluated to assess the extent to which participants were practicing selected behaviors linked to reducing the risk of foodborne disease both before and after the program. Scores from the state health department's Certified Food Manager (CFM) exam also were examined. Based on the 189 usable surveys returned, most respondents were female, middle age, and white with nearly 11 y of foodservice experience. Results revealed that after completing the program, participants reported practicing behaviors related to hand washing, maintaining safe food temperatures, preventing crosscontamination, and pest management more frequently (P < 0.05) compared to before the program. Effect size analysis indicated these results were also practically significant. Most (82.5%; n= 156) participants passed the CFM exam. Compared to those who failed the CFM exam, those who passed reported significantly higher changes in the adoption of selected behaviors; however, these results were of limited practical significance according to effect size analysis. Results suggest the food safety program is effective in promoting the adoption of food safety behaviors that can help reduce the risk of foodborne illness.
The Centers for Disease Control and Prevention (CDC) estimate that foodborne diseases in the United States cause nearly 76 million illnesses, 325,000 hospitalizations and 5000 deaths each year, costing more than $6.9 billion (Mead and others 1999).
Most reported foodborne disease outbreaks stem from foods prepared outside the home (Lynch and others 2006). The most common factors contributing to foodborne disease outbreaks include safe holding of food (time/temperature), contaminated equipment, food from unsafe sources, poor personal hygiene, and inadequate cooking (FDA 2004; Lynch and others 2006).
Foodservice employees play a pivotal role in assuring that the foods prepared and served to customers are safe for consumption. Unfortunately, studies involving foodservice workers in the Unites States suggest that some employees engage in unsafe food handling practices that could put the public at risk for a foodborne illness. For example, Green and colleagues (2005) found that more than half of the foodservice workers surveyed did not use a thermometer to check the food temperatures and 60% did not always wear gloves when handling ready-to-eat foods. In a study of 35 childcare centers in Texas, 40% and 54% of hot and cold foods, respectively, were not held at safe temperatures. (Staskel and others 2007). Poor personal hygiene also has been a documented problem (Giampaoli and others 2002; Burt and others 2003; Allwood and others 2004; Green and Selman 2005; Green and others 2005, 2006; Staskel and others 2007).
To promote the safe handling of food and to reduce the risk of foodborne disease outbreaks, state and/or local health departments may require the presence of a Certified Food Manager (CFM) in food establishments. CFMs have received additional food safety training (either through self-study or completion of an approved course) and successfully passed a certification exam. Research suggests the presence of a CFM can promote the adoption of critical behaviors, especially personal hygiene (FDA 2004).
To meet the needs of retail food establishments in Texas, which are required to have a CFM, the Texas Cooperative Extension developed a CFM program called Food Safety: It's Our Business (FSIOB). Accredited by the Texas Dept. of State Health Services (DSHS), the program prepares foodservice workers to take the state's CFM exam. Trained county Extension agents, recognized by DSHS as qualified instructors, teach the course over a 1- or 2-d period based on the needs of local clientele. The program utilizes a lecture style format with interactive activities that incorporate key aspects of the Texas Food Establishment Rules (Texas Dept. of State Health Services 2006) including the use of temperature control measures, safe hygiene (including hand washing practices), practices to avoid crosscontamination, and the adoption of pest management practices to control disease-causing pests.
Previously, the FSIOB program has been evaluated by an external agency through the use of a statewide telephone survey. Using this method can be costly and requires that participants have access to a telephone; however, it can be advantageous when there is concern about the literacy skills of the participants. A previous evaluation of the FSIOB program found that 6.9% of the 175 participants surveyed had less than a high school degree (Fletcher 1997). In 2005, the authors employed a mailed survey technique not only to reduce cost but also to evaluate the effectiveness of this method of evaluation. Because of the technical nature of the subject matter and the fact that the program participants have varying levels of education, the purpose of this study was to assess the feasibility of conducting the evaluation using a mailed survey technique as well as evaluate the impact of the FSIOB program (CFM exam score and self-reported change in behaviors).
Materials and Methods
All FSIOB participants (n= 710) who completed the program over 1 or 2 d between 2005 January and July were invited to participate in a retrospective postevaluation to determine the extent that targeted food safety behaviors were being adopted in their workplace. Because Texas Cooperative Extension is a provider of the DSHS CFM exam, exam scores for all participants were available. Procedures outlined in Dillman's tailored design method were used for mailed survey implementation and data collection (Dillman 2000). Participants were first mailed a letter (in both English and Spanish) informing them that a survey was forthcoming. Approximately 1 wk later, they were mailed the survey (both English and Spanish) along with instructions for completing the survey instrument. No other assistance in completing the survey was provided by the researchers. A self-addressed stamped envelope was included to facilitate the return of the survey. Two weeks later, those individuals who had not returned the survey were sent a 2nd survey and a self-addressed envelope. Data collection began 2005 October and was completed by 2005 December. The protocol for this evaluation was approved by the Texas A&M University Institutional Review Board.
The survey instrument utilized in this study was originally developed by a subject matter Extension specialist and an evaluation Extension specialist. It was then reviewed by 3 food safety educators for content and face validity. After minor corrections were made based on this feedback, the instrument was deemed ready for implementation.
The instrument, a retrospective postsurvey, originally administered by telephone, was adapted so data could be collected by mail. A retrospective post has been shown to be useful in reporting actual changes in behavior when compared to a pretest/posttest strategy (Rockwell & Kohn 1989). Through the use of a single survey instrument (available from the author) administered after completing the FSIOB program, participants were asked to reflect on the extent to which they practiced 12 food safety behaviors, before and after completing the program.
Participants self-reported the frequency they practiced the behaviors using a 3-point rating scale (1 =never; 2 =sometimes; 3 =always; selections also included not applicable and no response) before and after attending FSIOB program. Analysis of internal consistency (Cronbach alpha = 0.88 for pre and 0.85 for post) showed that the behavioral questions asked pre and post were within an acceptable range for reliability (Gall and others 1996).
The instrument itself was 2 pages (front and back document). The 1st section asked before and after behaviors related to the 12 practices. This section also contained an “NA” if the practice did not apply to their business. The next section focused on the business the respondent represented. This included the total number of employees, average number of meals served, county, and years the respondent had been in the foodservice/restaurant business. Following Dillman's (2000) suggestions, the final section focused on respondent demographics. This included position title, ethnicity, age, and gender. The instrument also provided return instructions at the very end.
In addition, questions about the number of meals served per day and the number of hours of food safety training provided to employees in their foodservice establishment along with selected demographic questions were included. Of the 710 surveys sent, 207 (29%) were returned of which 189 (26.6%) were used for data analysis. CFM exam scores used in the data analysis were limited to those participants with a complete survey.
SPSS 15.0 for Windows was used for analysis. Reliability (internal consistency) of the behavior scale was estimated from these data using the Cronbach alpha model.
For each behavior that the participant reported a pre- and postresponse, a mean score was calculated (excluding “not applicable” and “no response”) to determine the extent that the behavior was being following before and after the program. The amount of change reported for each of the behaviors was determined by subtracting each respondent's postscore from their prescore and then calculating the mean of the individual scores. For example, if an individual reported washing their hands for 20 s using soap and hot water “always” after participating in FSIOB but only “sometimes” before FSIOB, the change in performing that behavior was calculated as a 1 (always – sometimes = 1). A paired sample t-test was then used to test for statistical significance (program impact). We also determined the effect size for each behavior, since significant outcomes do not provide information regarding the practical significance or importance of an outcome. We estimated the effect size using Glass's Δ. Using published guidelines for effect size interpretation, values of 0.20, 0.50, and 0.80 were considered small (negligible practical significance), medium (moderate practical significance), and large (crucial practical significance), respectively (Hojat & Xu 2004; Kline 2004). Analysis of variance (ANOVA) was utilized to compare exam scores by job title and by length of course completed (1-d compared with the 2-d course). The significance level was set a priori at 0.05.
Results and Discussion
Respondent characteristics are shown in Table 1. Of the 189 surveys analyzed, 16 (8.5%) were returned in Spanish. Most program participants were female and Anglo although other ethnic groups were represented. Most participants were categorized into one of 3 age ranges; 30 to 39 y, 40 to 49 y, or 50 to 69 y. The job title of the participants also varied, with 36% of respondents identifying themselves as the manager or assistant manager and an additional 21% as the cook of their foodservice establishment. Respondents had been employed in the foodservice industry for an average of 10.9 y (SD = 9.8; range = less than 1 to 40 y). On average, the foodservice establishments where the participants were employed served 242 customers a day and employed 11 full- and/or part-time workers.
Table 1—. FSIOB respondent demographics and general characteristics
| Male|| 37||20a|
| Female||148||78 |
| No response|| 4|| 2 |
| Under 30 y|| 16|| 9 |
| 30 to 39 y|| 40||21 |
| 40 to 49 y|| 61||32 |
| 50 to 59 y|| 45||24 |
| 60 y and older|| 23||12 |
| No response|| 4|| 2 |
| African American|| 12|| 6 |
| Hispanic|| 50||27 |
| Anglo||116||61 |
| Other|| 2|| 1 |
| No response|| 9|| 5 |
|Job title |
| Assistant manager|| 13|| 7 |
| Cook|| 40||21 |
| Dietary services director|| 4|| 2 |
| Manager|| 54||29 |
| Owner|| 40||21 |
| Supervisor|| 18||10 |
| No response|| 20||11 |
Certified Food Manager score results
Test scores from the CFM Exam were available for all 189 respondents at the time of data analysis. Overall, 82.5% (n= 156) of the course participants passed the CFM exam (minimum score required to pass is 74). For the 169 respondents who identified their job title, 83.4% (n= 141) passed the CFM exam with a score of 74 or above. Mean scores along with the percentage of respondents passing the CFM exam by job title are shown in Table 2. An ANOVA of CFM exam scores found that those who classified their job as a “supervisor” scored significantly higher (P < 0.05) than those with a job title of “cook” or “owner.”
Table 2—. Mean scores and percentage of respondents who passed/failed the CFM exam, by job title
|Supervisor||18||87.3a ||18 (100)|
|Dietary services director|| 4||86.2ab|| 4 (100)|
|Assistant manager||13||83.5ab||11 (85) |
|Manager||54||83.0ab||48 (89) |
|Cook||40||79.7bc||30 (75) |
|Owner||40||79.3bc||30 (75) |
Most (n= 163, 86%) participants completed the FSIOB program over a 2-d period. Among those individuals, 131 (80.4%) passed the CFM exam. For those who completed the program in 1 d (n= 26, 14%), 24 (92%) passed the exam. Exam scores between the lengths of the program (1 d compared with 2 d) were not significantly different (mean [SEM] 1-d exam score = 82.7 [1.69]; 2-d exam score = 81.5 [0.96]).
Self-reported retrospective change in behaviors
Table 3 represents respondents self-reported food safety practices before and after completing the course. Before the course, fewer than 40% of respondents indicated they always followed 4 of the 12 behaviors prior to completing the program. These included: “Measure internal temperature of hot/cold-foods being held at least every 2 h,”“Use a thermometer to determine the doneness of food,”“Use the 2-stage cooling method to cool foods to 41 °F or below,” and “Show employees safe hand washing techniques.”
Table 3—. Extent to which participants adopted selected food safety behaviors before and after completing the FSIOB program
|Maintain food temperature at 41 °F or below for cold holding||4 (2.2)||44 (24.6)||123 (68.7)||1 (0.6)||5 (2.8)||165 (92.2)||2.7 (0.04)||2.9 (0.02)c||0.57|
|Measure internal temperature of hot/cold foods being held at least every 2 h||35 (19.6)||62 (34.6)|| 60 (33.5)||4 (2.2)||21 (11.7)||132 (73.7)||2.2 (0.06)||2.8 (0.04)c||0.93|
|Date mark all ready-to-eat refrigerated potentially hazardous foods||12 (12.8)||40 (22.3)||102 (57) ||1 (0.6)||10 (5.6) ||157 (87.7)||2.5 (0.07)||2.9 (0.02)c||0.60|
|Use a thermometer to determine the doneness of food||30 (16.8)||50 (27.9)|| 73 (40.8)||5 (2.8)||21 (11.7)||128 (71.5)||2.3 (0.06)||2.8 (0.04)c||0.65|
|Use the 2-stage cooling method to cool foods to 41 °F or below||40 (22.3)||51 (28.5)|| 60 (33.5)||4 (2.2)||22 (12.3)||128 (71.5)||2.1 (0.06)||2.8 (0.04)c||0.80|
|Wash hands for 20 s using soap and hot water||6 (3.4)||46 (25.7)||123 (68.7)||1 (0.6)||5 (2.8)||166 (92.7)||2.7 (0.04)||2.9 (0.02)c||0.53|
|Show employees recommended hand washing techniques||30 (16.8)||44 (24.6)|| 88 (49.2)||3 (1.7)||18 (10.1)||142 (79.3)||2.4 (0.06)||2.9 (0.03)c||0.63|
|Clean and sanitize cutting boards between uses||11 (6.1) ||24 (13.4)||133 (74.3)||1 (0.6)||5 (2.8)||163 (91.1)||2.7 (0.04)||2.9 (0.02)c||0.41|
|Clean equipment, utensils, and any food contact surfaces that are used for preparing potentially hazardous foods at least every 4 h||14 (7.8) ||32 (17.9)||118 (65.9)||2 (1.1)||9 (5.0)||156 (87.2)||2.6 (0.05)||2.9 (0.02)c||0.46|
|Clean and sanitize all clean-in-place equipment every day||7 (3.9)||42 (23.5)||122 (68.2)||1 (0.6)||12 (6.7) ||160 (89.4)||2.7 (0.04)||2.9 (0.02)c||0.42|
|Store raw foods below ready-to-eat foods in the refrigerator||12 (6.7) ||37 (20.7)||105 (58.7)||5 (2.8)||4 (2.2)||144 (80.4)||2.6 (0.05)||2.9 (0.03)c||0.47|
|Minimize the presence of pests, insects, and rodents on premises through routine inspections and control measures||2 (1.1)||29 (16.2)||144 (80.4)||0||6 (3.4)||170 (95.0)||2.8 (0.03)||2.9 (0.01)c||0.40|
After the program, at least 80% of the respondents indicated they always practiced 8 of the 12 behaviors. These 8 statements included: “Maintain food temperature at 41 °F or below for cold holding,”“Date mark all ready-to-eat refrigerated potentially hazardous foods,”“Wash hands for 20 s using soap and hot water,”“Clean and sanitize cutting boards between uses,”“Clean equipment, utensils, and any food contact surfaces that are used for preparing potentially hazardous foods at least every 4 h,”“Clean and sanitize all clean-in-place equipment every day,”“Store raw foods below ready-to-eat foods in the refrigerator,” and “Minimize the presence of pests, insects, and rodents on premises through routine inspections and control measures.”
Respondents indicated a significant increase (P < 0.05) in all 12 food safety practices after participating in the course (Table 3). Effect size analysis indicated that several changes were large (practically significant). These included measuring the internal temperature of hot/cold food being held and use of the 2-stage cooling method. Those changes that were of a medium effect size (moderate practical significance) were maintaining safe food temperature for cold holding, date marking ready-to-eat refrigerated food, using a thermometer to determine the doneness of food, washing hands safely, and showing safe hand washing techniques to employees.
When the degree of behavior change was compared among those individuals who passed and failed the CFM exam, individuals who passed the exam reported a significantly higher change (P < 0.05) in the adoption of several behaviors: frequency of using the 2-stage cooling method, frequency of washing hands for 20 s with soap and hot water, frequency of showing employees recommended hand washing techniques, and frequency of cleaning and sanitizing all clean-in-place equipment every day (Table 4). Effect size analysis of the 2 groups revealed that these differences were of limited educational importance, suggesting that participants adopted safe food handling practices, regardless if they passed the exam or not. The degree of behavior change was also examined based on the length of the FSIOB course (1 d compared with 2 d). Individuals who completed the FSIOB program over a 2-d period reported significantly greater change in the extent to which they date marked refrigerated foods (mean change [SEM] in behavior for 1-d participants = 0.19 (0.08); 2-d participants = 0.48 [0.06]; P < 0.05). No other behavioral differences were identified between these groups. Because of small categorical size, changes in behaviors were not analyzed according to job titles.
Table 4—. Amount of change in food safety behaviors among individuals who passed and failed the CFM exam
|Cleaning and sanitizing all clean-in-place equipment every day||Pass 145||0.25 (0.04)||<0.05||0.11|
|Fail 33||0.09 (0.05)|| |
|Using the 2-stage cooling method to cool foods to 41 degrees or below||Pass 127||0.71 (0.07)||<0.05||0.14|
|Fail 30||0.40 (0.12)|| |
|Washing hands for 20 s using soap and hot water||Pass 127||0.71 (0.07)||<0.05||0.08|
|Fail 30||0.40 (0.12)|| |
|Showing employees recommended hand washing techniques||Pass 149||0.31 (0.04)||<0.05||0.16|
|Fail 31||0.10 (0.05)|| |
|Maintaining food temperatures at 41 degrees or below||Pass 146||0.25 (0.04)||NSa||0.02|
|Fail 33||0.36 (1.0) || |
|Measuring internal temperature of hot/cold foods being held at least every 2 h||Pass 132||0.67 (0.06)||NSa||0.29|
|Fail 32||0.50 (0.13)|| |
|Date marking all ready-to-eat refrigerated potentially hazardous foods||Pass 142||0.46 (0.06)||NSa||0.06|
|Fail 31||0.32 (0.11)|| |
|Using a thermometer to determine the doneness of food||Pass 127||0.51 (0.06)||NSa||0.31|
|Fail 32||0.43 (0.11)|| |
|Cleaning and sanitizing cutting boards between uses||Pass 144||0.23 (0.04)||NSa||0.08|
|Fail 31||0.26 (0.09)|| |
|Cleaning equipment, utensils and food contact surfaces used for preparing potentially hazardous foods every 4 h||Pass 141||0.32 (0.05)||NSa||0.08|
|Fail 32||0.15 (0.08)|| |
|Storing raw foods below ready-to-eat foods in the refrigerator||Pass 131||0.31 (0.05)||NSa||0.25|
|Fail 29||0.21 (0.09)|| |
|Maintaining proper pest controls as specified by HACCP law and code||Pass149||0.19 (0.03)||NSa||0.02|
|Fail 32||0.19 (0.09)|| |
Respondents (n= 117) reported that the amount of time they spent training employees about food safety rose from 5.6 h before participating in FSIOB to 9.4 h afterward (P < 0.05). Another noteworthy finding was that 81.3% (n= 148) of the respondents identified FSIOB as their first Cooperative Extension program ever attended.
Based on self-reports from participants, results of this evaluation suggest that the FSIOB program is effective in promoting the adoption of specific food safety behaviors and in helping individuals prepare for the state CFM exam. Our findings are congruent with McElroy and Cutter (2004) who, using a similar evaluation strategy, found an increased likelihood of using food thermometers to check temperatures, holding hot and cold food at 140 and 41 degrees, respectively, date marking stored foods, and washing hands properly after completing their Statewide Food Safety Certification program. Our results also add to the existing literature (Kirby and Gardiner 1997; Cotterchio and others 1998; Martin and others 1999) that supports the use of food safety education to promote the adoption of desired food handling practices.
Results of paired sample t-tests indicate that participants made significant (P < 0.05) improvements in food safety practices that can decrease the risk of foodborne disease outbreaks. Many of these changes were also practically significant. The extent to which behaviors were changed by whether or not individuals passed or failed the CFM exam or completed the FSIOB course in 1 or 2 d is of interest and warrants further investigation with a larger sample of individuals.
Our analysis indicated that the instrument was reliable in evaluating the program's effectiveness. Administering this instrument to participants throughout the year by mail may help increase sample size that would then lend itself to a more in-depth statistical analysis of the data.
While the results of our evaluation are encouraging, they must also be interpreted with caution. The small sample size prevents extrapolating the results to all FSIOB participants across the state. In addition, it is recognized that asking the extent to which some of the food safety behaviors are adopted in the workplace may be viewed as “socially loaded,” prompting participants to acknowledge adopting a behavior because it is the answer one is supposed to give. For example, one would likely assume that all individuals would admit to washing his/her hands for 20 s with soap and hot water all of the time. Yet 3% (n= 6) of the respondents admitted that they did not do this in the workplace prior to the FSIOB program. Even after the program, 1 of the participants did not adopt this behavior and 7 individuals refused to answer the question. While some food safety practices were not applicable to all respondents due to the type of foodservice operation where they are employed, the finding that some participants were not adopting recommended hand washing practices, utilizing food thermometers, or taking steps to prevent crosscontamination are of concern since these are important in the prevention of a foodborne disease outbreak. Our results could be used to help owners and managers identify topics for additional food safety training. Interestingly, during the course of this evaluation, we received written requests from 3 respondents asking the authors to contact their local health department and report their place of employment for poor food handling practices by their fellow employees.
For a majority of the respondents in this study, the FSIOB program appears to be their first exposure to Texas Cooperative Extension. This suggests that the program is reaching an audience who might otherwise not have the opportunity to benefit from the numerous programs Extension offers. Using FSIOB or similar food safety programs as a gateway program may be an effective mechanism in marketing Cooperative Extension programs.
The authors extent an appreciation to Dr. Christine Bruhn, Director, Center for Consumer Research at University of California, Davis for reviewing the manuscript.