A Comparison of Perspectives About the Critical Areas of Knowledge for Safe Food Handling in Food Establishments.

Introduction

In the United States, an estimated 24 to 81 million people become ill each year from consumption of contaminated foods. These illnesses result in an estimated 10,000 deaths each year and have an estimated cost of between $7.7 and $23 billion (1). The Centers for Disease Control and Prevention (CDC) reports that many cases of foodborne illness originate from foods mishandled in food establishments, especially food retail and food service establishments (2). Foodborne illnesses that originate in food retail or food service establishments frequently occur because the food is 1) temperature abused, 2) handled with poor personal hygiene, and/or 3) inherently contaminated or exposed to some form of cross-contamination (3,4-6). Temperature abuse is the problem most often identified as a contributing factor in foodborne illness (2,4-6). Temperature abuse may consist of

* improper cooling,

* inadequate cooking or reheating,

* unsuitable thawing methods, or

* unsafe cold or hot holding practices.

In recent years, poor personal hygiene has increasingly been identified as a factor in foodborne illness, especially with the increased demand for ready-to-eat food items that come in contact with human hands. To reduce the transfer of harmful contaminants to foods, it is critical to know when and how to properly wash hands and to avoid bare hand contact with foods.

Many foods are inherently contaminated with disease-causing micro-organisms, especially foods of animal origin. Each year, red meat, poultry, and seafood products are the leading vehicles of reported cases of foodborne illness (2). Recent reports that some ready-to-eat foods, such as strawberries and raspberries, have been contaminated with viral and parasitic pathogens have raised concern about whether food is being safely handled. Food contamination is also an important factor in foodborne illness. Foods can be cross-contaminated from various sources such as human contact, contact with raw foods (especially of animal origin), and exposure to food contact surfaces (utensils, cutting boards). In addition to unclean hands, common vehicles of food contamination include soil, garbage, rodents, insects, and air.

The key to preventing and reducing foodborne illnesses associated with food establishments is educating and training food handlers (4,6). To be effective, food safety education and training must be supported by top management and at all levels of management in the food establishment. The FDA Food Code requires the "person in charge," often called a food manager, to be responsible for ensuring the safe preparation and delivery of food to the consumer (1). Ideally, food establishment managers receive food safety and sanitation training; in turn, the food manager trains employees at the food establishment, especially the front-line workers who are actively involved in handling, preparing, and serving food to the consumer.

Most food establishments are governed by state and local food codes; inspections are being carried out by personnel from local health departments or the Department of Agriculture. Although the frequency and format of food establishment inspections differ from state to state (and perhaps from county to county within each state), food codes generally have specific regulatory requirements for

* receiving, preparing, and serving foods;

* the health, cleanliness, and hygienic practices of food handlers; and

* facility design and food equipment specifications.

On a national scale, the U.S. Public Health Service (USPHS) and the Food and Drug Administration (FDA) provide recommendations for safe handling of foods in a document called the FDA Food Code. In 1993, the 1976 version of the Food Code was revised after a gap of nearly 20 years. The FDA Food Code is now revised every two years, and the most recent FDA Food Code was published in 1997. The Food Code is not a legally binding document. Each jurisdiction determines its own regulations for food establishments. The Food Code provides a set of recommendations for local, state, and federal governmental jurisdictions that are responsible for regulating food establishments.

The Conference for Food Protection (CFP) includes representation from all segments of the retail food industry (food retail, food service, food vending), as well as regulatory agencies and academia. One of the primary goals of the CFP is to evaluate issues and recommend [TABULAR DATA FOR TABLE 1 OMITTED] changes for the next version of the FDA Food Code, as appropriate. A Food Manager Certification Subcommittee was established in 1993 and is responsible for recommending critical competencies as well as a protocol for a program to certify food establishment managers. This subcommittee has created a document that describes knowledge and competencies essential for food establishment managers (7).

Requirements for existing food certification programs vary greatly throughout the United States. Some states and local jurisdictions have mandatory food certification programs and others offer food certification on a voluntary basis. Some of the jurisdictions with mandatory certification require only a passing score on an approved examination, while other states have training requirements fulfilled through an approved food safety education course. Some local jurisdictions require recertification every few years. As of 1996, 20 states and the District of Columbia encouraged voluntary food safety training and 30 states had mandatory food certification programs in some or all counties (7,8).

The primary objective of this study was to determine what knowledge and task skills are needed for safe food handling practices in food establishments and to rank those knowledge and task skills by importance. This information is useful in the development stages of food safety education and training programs and for the development of a food safety competency examination. Food safety experts, academia, the food industry, and regulatory agencies collectively determined the critical knowledge areas and tasks through a practice commonly known as task analysis. The list of competencies was validated and ranked by importance according to survey responses from representatives of the food industry, regulatory agencies, academia, and other special interest groups. An additional objective was to determine if the responses of the food industry and regulatory respondents differed. Understanding similarities and potential differences between these groups will also help in the food safety education process. To accomplish this objective, the distributions of responses in the two respondent groups were compared.

Materials and Methods

Development of a Task Analysis

An advisory board of six individuals was established. The board included food scientists, food safety professionals, and psychometricians. The purpose of the advisory board was to determine food safety competencies, skills, and knowledge needed by personnel working in food establishments. The advisory board worked with members of local and state [TABULAR DATA FOR TABLE 2 OMITTED] regulatory agencies and food service and food retail industries to establish a task list. The advisory board's approach to task analysis involved the following procedures:

* A detailed literature search was conducted to identify existing data related to competencies and skills needed by food establishment workers. After analysis of related literature, the advisory board convened to develop a draft list of minimal competencies and skills of safe food handling needed for entry-level food establishment workers.

* The advisory board developed the safe food handling task list into knowledge areas, related tasks, and specific subtasks for each of the competencies (Table 1). The tasks described generalized responsibilities within each knowledge area. The subtasks further clarified each task. Five knowledge area groups were identified: 1) food; 2) cleaning, sanitizing, and maintenance; 3) facilities; 4) food personnel; and 5) legal and regulatory issues.

* Twenty tasks and 47 sub tasks were used to delineate the knowledge areas.

* The draft task list was reviewed by a group of food safety experts from around the country. Reviewers were asked to comment on the task statements and to provide suggestions, additions, and deletions. All input from the reviewers was studied, and the original task list was modified to include the reviewers' recommendations.

Validation of the Task List

The task list was then validated with a large-scale survey. A total of 2,000 task list validation surveys were mailed out. Because the task list was detailed and lengthy, it was determined that an individual respondent would have to devote too much time to review the entire list. Therefore, the task list was divided into eight separate surveys, each of equal proportions. Each survey also included demographic questions. Respondents were randomly selected from mailing lists obtained from the following associations and groups:

* Association of Food and Drug Officials;

* Conference for Food Protection, Food Manager Certification Committee;

* Food Marketing Institute;

* Inflight Food Service Association;

* International Association of Milk, Food, and Environmental Sanitarians, Inc.;

* National Automatic Merchandising Association; and

* National Environmental Health Association.

[TABULAR DATA FOR TABLE 3 OMITTED]

Distribution of the surveys was arranged to ensure appropriate geographical representation and job title representation.

Demographic Information

Respondents were asked to provide information about eight topics related to demographics. They were asked 1) to indicate their highest level of education; 2) to indicate the type of environment in which they currently worked; 3) to select the area in which they worked if they worked in a food industry; 4) to describe their main work responsibility if they worked in a food industry; 5) to select the area in which they worked if they worked in an institutional setting; 6) whether they held the position of Certified Food Manager in any jurisdiction; 7) whether their jurisdiction required certification of food handlers; and 8) what state they worked in.

Scoring and Ranking of Knowledge Areas and Tasks

Respondents were asked to rate the importance of each knowledge area in protecting the public from harm on a five-point scale as follows:

* 1 = of no importance,

* 2 = of little importance,

* 3 = moderately important,

* 4 = very important, and

* 5 = extremely important.

Tabulation of Survey Results

Data from all respondents were used to tabulate mean (average) response scores and to rank the tasks within each knowledge area. Mean scores enabled comparisons of importance for each of the responses. Two subsets of the data, responses from regulatory personnel and responses from the food industry, were pulled from the total data set. A Kolmogorov-Smirnov Z-test procedure was used to compare the distribution of response scores among regulatory personnel with the distribution of response scores from the food industry for each task (9). This statistical method was used to determine differences in both the locations and shapes of response distributions for each knowledge area and each task.

Results and Discussion

A total of 2,000 task list validation surveys were mailed. (Recall that the surveys were divided into eight parts). Of these, 302 surveys were returned and used in the analysis. Demographic [TABULAR DATA FOR TABLE 4 OMITTED] information about survey participants is summarized in Table 2. The return rate varied from approximately 35 to 45 returns per survey form. This translates to a rate between 14 and 18 percent.

Two hundred and three individuals indicated their highest level of education. The majority of individuals (50.5 percent) had a bachelor's degree, and 27.5 percent indicated that their highest level of education was a master's degree. The advisory board felt it was important to determine the type of work environment in which each respondent worked because this circumstance may have a direct impact on the level of importance the respondent placed on certain tasks. The majority of respondents worked in industry (51.2 percent). The second largest group (39.3 percent) worked in a regulatory environment.

If a respondent indicated that he or she worked in the food industry, the advisory board felt it was important to know which area in the food industry. The largest number (55.5 percent) indicated that they worked in industry but chose the "other" category rather than one of the listed options. A number of handwritten responses indicated locations such as vending, commissary, food processing/production/manufacturing, and private laboratories.

In addition to identifying the area of the food industry in which an individual respondent worked, it was also important to identify the actual job responsibility of the respondent. A large number (39.8 percent) of the respondents were quality control specialists. Quality control specialists would be familiar with the skills and tasks that are essential in protecting the public from harm. The largest response (40.4 percent) was in the "other" category. Many of these respondents viewed themselves neither as quality control specialists nor as holding any sort of position related to food service.

For the small number of respondents (2.6 percent) who worked in an institutional setting, the advisory committee wanted to know the type of establishment. Again, the largest response was "other," with many respondents indicating that they worked in schools of higher learning. The respondents apparently viewed schools of higher learning as distinct from the "schools" category.

The next question asked if the respondent was certified. Of the 266 participants who responded to this question, a high number (42.9 percent) indicated that they were certified. The last question asked respondents to identify the state where they worked. Responses from 45 states were represented in the survey.

Table 3 presents the respondent scores and rank of each task for the total data set, as well as for regulatory and food industry respondents. Ensuring food protection; preparing foods; monitoring personal behaviors related to food safety; monitoring personal hygiene and personnel; and cleaning and sanitizing equipment, utensils, and food contact surfaces were the tasks identified as most important by the respondents. This information was reassuring since most of the factors contributing to foodborne illness (temperature abuse, poor personal hygiene, contamination, and cross-contamination) are addressed by these tasks. Tasks related to the knowledge of food personnel were emphasized. The tasks identified as least important were those related to ventilation systems and equipment.

The comparison of the mean scores and rankings among regulatory and food industry respondents showed many similarities. "Ensuring food protection" was ranked highest in each respondent group. "Preparing foods," "monitoring personal behaviors related to food safety," and "monitoring personal hygiene and personnel" also ranked among the top five. Good agreement was observed in mean scores and ranking for the food personnel knowledge area group, which was again an emphasis of importance. Striking differences in means and ranking were noted for two tasks: (1) using and maintaining tools and equipment and (2) selecting, monitoring, and maintaining water sources. Using and maintaining tools and equipment received a much higher score and ranking among food industry respondents. By contrast, selecting, monitoring, and maintaining water sources received a higher score and ranking from regulatory respondents.

Although mean scores and ranking are useful, an understanding of respondent score distributions would better describe differences between regulatory and food industry respondents. A distribution comparison of regulatory and food industry respondents revealed a significant difference (p [less than] .01) in distribution shape for four different tasks:

1. using and maintaining tools and equipment,

2. monitoring and maintaining ventilation systems,

3. performing general maintenance and housekeeping duties, and

4. ensuring that proper ventilation equipment is used.

Distributions were plotted for each task that was identified as significantly different between regulatory and food industry respondents [ILLUSTRATION FOR FIGURES 1, 2, 3, AND 4 OMITTED]. The distributions for each of the four tasks revealed an interesting trend. All four were more important to the food industry respondents than to the regulatory respondents. For the food industry respondents, more responses were identified as the level of importance increased, whereas responses from regulatory personnel presented a bell-shaped curve and peaked at "moderately important."

Conclusions

In past years, the emphasis in prevention of foodborne illness has been to ensure safe handling of foods using a "farm-to-fork" approach. The retail food industry, especially food service and retail food stores, represents a critical link in the food distribution chain. Ensuring safe handling of foods is especially important for retail food establishments since they are often the final handling sites before consumption of a food.

Education, training, and the development of food safety certification examinations are key components in the process of ensuring that food handlers are proficient in and knowledgeable about food safety and sanitation principles. Understanding knowledge areas that are most critical for ensuring food safety will help in the development of effective educational and training programs. It will also assist regulatory authorities who are responsible for inspection of retail food establishments.

The relationship between retail food industry workers and regulatory officials is an important one. Ensuring the safe handling, preparation, and service of foods to the consumer in retail food establishments is the joint responsibility of the retail food industry and the regulatory authority. Food industries and regulatory authorities can foster their relationship by understanding each others' differing perceptions and emphasis of food safety competencies.

REFERENCES

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