Engaging food service workers in behavioral-change partnerships.

Introduction

Local government health promotion programs are essential to reducing disease risks and improving the health and well-being of individuals. Food protection programs typically use legislative and regulatory approaches, which are often cited as the most potent means of facilitating healthful behavior (Breslow, 1973; Institute of Medicine, 1979). Regulatory approaches alone, however, do not necessarily ensure adoption of the regulated behavior. As a result, restaurants may repeatedly commit food safety violations upon inspection and may incur closures.

Many program planners believe that by enhancing knowledge or altering attitudes, they can induce behavioral change. Numerous studies document that education alone may not result in behavioral change, and that to change most complex behaviors, multifaceted approaches are needed (McKenzie-Mohr & Smith, 1999). To influence what food workers do and how they do it, it is necessary to understand what they perceive to be the barriers to and benefits of an action; those perceptions underlie the behavioral choices they make. Food protection programs may be more effective when barriers are removed and benefits are enhanced so that the target behavior becomes more attractive.

Food protection programs may be more likely to succeed if they are based on a clear understanding of target behaviors identified by a needs assessment and on the use of behavioral-change models that address improper food-handling methods. Behavioral-change theories provide guidance in addressing questions about why individuals act, what they do, and how they do it, as well as how they think with respect to issues of proper food handling. In this way, they guide the investigation into why people are not taking preferred actions (Glanz, Lewis, & Rimer, 1997). They provide insight into the shaping of program strategies and the choice of items to be measured in a program evaluation. Identifying barriers to desirable behavior (i.e., the mutable causes of failure to apply those behaviors) lays the groundwork for planners to determine what theories will be most appropriate to change behavior. To achieve needed constituency involvement, a public health leader must understand what motivates and moves constituents to action on public health issues (Nicola, Ray, & Hatcher, 2000).

"Mutable causes" are the behavioral barriers that influence people's actions and thought processes. With respect to a desired behavior, environmental health programs should address mutable causes, not the incident or the prevalent problem. If environmental health specialists understand a mutable cause, such as the reason a food worker is using improper cooling methods, the problem can be addressed within a context that is understood. In this way, the behavior may be changed, and repeat violations could be eliminated.

The study reported here took as its hypothesis the proposal that sustainable improvements in food safety, as measured by food service inspection scores, can be achieved through the systematic application of behavioral-change theory in active partnership with industry. To test that hypothesis, the authors worked with Key Arena Sportservice, a sports arena in Seattle, Washington, that serves 1.2 million customers per year through 40 individual food service operations staffed by approximately 250 workers.

Methods

Key Arena's food inspection reports from 1996 through 2000 were reviewed. The review covered 389 inspection reports for 36 facilities. The three areas of violation that consistently represented the majority of citations were handsink/handwashing, improper storage of ice scoops, and lack of sanitizer (Table 1). These violations were selected for the comparison because environmental health specialists identified them as chronic problems. Hot-holding was seen as an anomalous problem, with more than 60 percent of the violations occurring in a single year, 1996.

A written survey was conducted of management and food staff (156 respondents were surveyed) to help identify the "mutable causes" involved in the frequency with which violations of these three types occurred. The survey results were used to develop strategies for motivating food workers to change their behavior. Environmental health specialists worked with management to develop a training plan and management intervention.

Theories and Influencing Action

The authors' needs assessment helped identify four applicable behavioral-change theories: Health Belief Theory, Consumer Information Processing Theory, Social Learning Theory, and Social Cognitive Theory. Table 2 lists these theories and related materials, including the application of the theories, sample responses from the survey needs assessment, and actions that may influence behavioral change.

If any form of sustainable behavior change is to be adopted by food service workers, the mutable causes involved in the activity must be identified. For example, a mutable cause internal to food staff involved a lack of knowledge with respect to the question "How do you know if a food is in the proper temperature zone?" (77.8 percent responded correctly, 22.2 percent incorrectly). External mutable causes also were noted; certain management decisions could make behavior change more convenient, such as providing ice scoop holders or sanitizing systems. Solution strategies were devised after stakeholders identified mutable causes that commonly discourage people from the desired behaviors. Table 3 demonstrates how program interventions were changed to effect the desired behavior change.

Captivate the Audience and Use Alternative Teaching Methods

How do environmental health professionals capture the attention of food service workers they wish to persuade? This study conducted a survey that identified worker interests in order to recruit worker participants. Half of the survey respondents (156 were surveyed) said that they would prefer to learn by practical hands-on experience, followed by 22 percent who preferred visually interesting presentations and 20 percent who preferred demonstrations. The survey indicated that the least effective way to get the workers' attention was through the two main teaching tools used by many public health officials--printed material (preferred by 4 percent) and videos (preferred by 4 percent) and videos (preferred by 5 percent). Interest in practical, hands-on exercises was strong. One of the solutions, therefore, involved setting up a "mock" restaurant as a training program. Food staffs were asked to play the role of an environmental health specialist and were equipped with clipboard, inspection form, thermometer, and sanitizer test paper. Upon completion of the inspection, individual reports were self-graded and environmental health specialists were on hand to answer any questions. Participants' comments were universally positive. Comments included the following: "The exercise was a good solution to help improve awareness of safe food preparation," "Finally I learned how to 'temp' food," and "I didn't understand how to check for sanitizer." In the comment section of the evaluation, many staff suggested the exercise become a permanent training exercise.

Restaurant workers were asked, "If you were the inspector, how would you get people to change improper food preparation methods?" Responses included education (55 percent), negative reinforcement (40 percent), and positive reinforcement (5 percent). Suggestions for education mainly emphasized hands-on learning experience. Negative-reinforcement suggestions included fining the restaurant, taking away its permit, or firing the employee. Positive-rein-forcement suggestions included incentives programs or rewarding people for doing things correctly.

Results and Analysis

The raw data collected for the periods before and after intervention are shown in Table 4. Since the numbers of inspections were dissimilar between the two periods, this simple tally is insufficient to suggest trends and effects. When expressed as percentages of inspections showing a given violation, however, the comparison indicates a marked drop in violation rates for each of the four targeted violation categories. In addition, when all of the nontargeted violations are subjected to the same calculation, a slight increase is noted (Table 5). This result is of interest, since the frequency of inspections increased in the post-intervention period, and other studies have postulated that violation rates will decrease with increased inspection frequency (Allwood, Borden-Glass, & Petrona, 1999). While that effect is demonstrated in the item labeled All Categories in Tables 4-7, it is remarkable to note that no significant change occurred in the nontargeted categories of violations.

Since these data were collected on a retrospective basis and were the product of many different inspectors, bias was not introduced into the inspection process itself. For a more powerful analysis of the data, odds ratios were calculated to validate the apparent positive effect of intervention strategies (Table 6). Odds ratios are intended to highlight potential cause-effect relationships. They do so by multiplying two fractions. The first fraction measures the effect of a variable, and the second measures the effect in the absence of the variable. In this case, the variable is intervention and the effect is no violations. Positive odds ratios indicate positive correlation (Figure 1). While the initial calculation of odds ratios for the same data categories does not eliminate the effects of increased inspection frequencies in the post-intervention period, the trends suggested in Table 4 and Table 5 remain after calculations for odds ratios are applied (Table 6, Table 7).

Discussion

The analysis of the data strongly supports the value of interventions based on behavioral-change theory. The use of percentages of inspections with violations as a basis for analysis (Table 5 and Table 7) averts any effect that an increased number of inspections may have had in the post-intervention period. A slight increase in violation rates in the nontargeted categories of violations seen in these data sets continues to support a correlation between intervention and behavioral change, and the analysis in Table 5 completes the validation of the authors' findings.

The results of this study indicate that behavioral-change partnership may improve inspection report scores. Since the introduction of government systems of food quality control, officials have recognized that along with appropriate regulations governing the retail food trade, regular inspection of food establishments is needed for education and enforcement purposes (Hanlon, 1960). Today, with advances in understanding of the factors that influence behavior change, education of food workers may play a far more significant role in promoting safe behavior than does enforcement (Allwood et al., 1999).

Behavioral-change professionals state that "the design of interventions that yield desirable changes can best be done with an understanding of theories of behavioral change and an ability to use them skillfully in practice" (Glanz et al., 1997). While instincts about how to involve the public can be useful, social science research is better (Chess, 2000).

The analysis by Sportservice management of operational barriers included an assessment of the potential risks of making policy or equipment modifications and the benefits of the outcome. Since use of safe technologies and operating procedures can minimize health risks to the public, management weighed the costs of changing equipment, such as sanitizer systems, against the potential public health risk the change might affect. Sportservice serves as many as 15,000 customers in a two-hour period. This rate requires a fast-paced, team-oriented spirit. Reducing barriers, increasing benefits perceived by staff, and eliminating potential causes of a disease outbreak would be less costly to the corporation than a disease outbreak.

The authors' process evaluation addressed how the strategies were affecting behavioral change. Midway through the project, it was found that some fine-tuning was needed to obtain the desired behavioral changes. For example, many food service workers have day and night jobs. With their busy schedules, the staff found it difficult to remember the proper food-holding temperatures. They requested additional signage to remind them of what the proper temperatures were for hot-holding foods. Sportservice changed products and recipes that affected food temperatures. Time-temperature charting made hot-holding more effective. These changes appear to have improved food-handling practices despite high rates of staff turnover in the Sportservice food businesses.

Conclusions

Greater success is achievable with the application of proven behavioral-change theories to the design and implementation of public education programs. These programs, if designed appropriately, will help environmental health specialists identify behaviors that reduce disease risks, improve understanding of disease prevention methods, and promote general health and well-being. In this study, public health inspections report scores showed marked improvements. Implementation of new strategies is a continuous effort by health departments and the food service industry.

Enforcement actions taken in response to an immediate public health risk often are only a temporary solution. Since inspections cover less than 0.05 percent of the time that an establishment may be operating, effective behavioral change must be maintained without constant and direct observation by an environmental health program. The framework for this study started with food service staff investing their energy to identify mutable causes, solutions, and preferred training methods.

Regulatory agencies cannot easily bring about internal or systemic changes on the strength of regulations alone. A partnership with management and food service workers helps environmental health programs find solutions that affect behavioral change. These changes may include new or revised policies, re-allocation of resources, and establishment of a new local government identity among business partners. Partnership empowers the private sector to suggest ways for local government and industry to obtain mutual benefits, such as a reduction in food service violations, while at the same time providing safe, wholesome food.

This study is a work in progress. It suggests that public health leaders advocate for new methods of providing food protection services. In other words, it requires public health leaders to "think outside the box" and to dedicate the time and resources necessary for development of effective partnerships. Environmental health staff may need training in these new skills and may need to be provided with methods of adapting effective interventions and activities to diverse cultures. Behavioral-change strategies, specific targeted education, and the fostering of local government and business partnerships are key to successful and sustainable behavioral change (Jenkins-McLean, 1991).

TABLE 1 Total Numbers of Violations Cited, by Type, 1996-2000

Raw meats stored over                    2
ready-to-eat foods
Improper cooling                         1
Room temperature storage                 0
of potentially hazardous
foods (70-120[degrees]F)
Room temperature storage                 5
(46-69[degrees]F or 121-139[degrees]F)
Cold-holding                             1
Hot-holding                             24
Handsink/handwashing                    36
Sneeze guards or double stacking         2
Ice scoop storage                       31
Sanitizer                               36

TABLE 2 Behavioral-Theory Application

                       Application of Theory:
                       What Makes People
Theory, Concepts       Do What They Do?        Sample Responses

Health Belief Theory:  One's opinion of the    "I didn't realize the
perceived severity,    advised action or       possible dangers."
perceived barriers     perception of the
                       seriousness of the
                       impact
Self-efficacy          One's opinion of the    "I don't have buckets for
                       tangible action         sanitizer solutions."
Social cognition       Confidence in one's     "The manager or
                       ability to take         supervisor checks
                       action                  temperatures--not me."
Consumer Information   Individual limitations  "I need reminders from
Processing Theory      on the amount of        the boss."
                       information workers
                       can acquire, use, &
                       remember
Information            Rules of thumb          "I need signs."
processing capacity    developed to help
                       follow procedures
Decision-making        Processing of acquired  "I'd like helpful
rules, information     information,            reminders in certain
search                 affected by             places."
                       motivation,
                       attention,
                       perception
Social Learning        Knowledge & skills to   "Tell me how to do
Theory                 influence behavior      something, show me,
                                               then tell me again."
Behavioral capability  Beliefs about likely    "The worker has an
                       results of action       irresponsible attitude,
                                               poor work ethic."
Expectations,          Responses to a          "Managers remind us
reinforcement          person's behavior       when job is done
                       that increase or        wrong."
                       decrease the chances
                       of recurrence
Social Cognitive       Knowledge & skill to    The food is okay to serve
Theory                 perform a given         "when it turns brown."
                       behavior

Theory, Concepts       Influencing Action

Health Belief Theory:  a. Specify consequences of the risk.
perceived severity,    b. Increase awareness of need for change.
perceived barriers     c. Personalize information on risks and benefits.
Self-efficacy          d. Provide how-to information, promote awareness,
Social cognition          and employ reminder systems.
                       e. Identify and reduce barriers through
                          reassurance, incentives, and assistance.
                       f. Provide training and guidance in performing
                          action.
                       g. Use progressive goal setting.
                       h. Use verbal reinforcement.
                       i. Demonstrate desired behaviors.
                       j. Reduce anxiety.
Consumer Information   a. Choose the most important and useful points to
Processing Theory         communicate, whether orally or in print
                          materials.
Information            b. Learn to synthesize information in ways that
processing capacity       have meaning and appeal to your audience.
Decision-making        c. Reminder minimizes effort required to obtain
rules, information        information, draws attention, & is clear.
search
Social Learning        a. Provide information & training about action.
Theory
Behavioral capability  b. Incorporate information about likely results
                          of action.
Expectations,          c. Provide incentives, rewards, praise; encourage
reinforcement             self-reward; decrease possibility of negative
                          responses that deter positive changes.
Social Cognitive       a. Promote mastery learning through skills
Theory                    training.

FIGURE 1 Odds Ratio Calculation

(na/vb) X (nb/va)

Where

na = inspections with no violations, post-intervention period,
nb = inspections with no violations pre-intervention period,
va = inspections with violations after intervention, and
vb = inspections with violations before intervention.

TABLE 3 Development of Solution Strategies

The Change or Desired Effect        How

Increase awareness of need for      Demonstrate proper handwashing,
change.                             testing of sanitizer strength,
                                    and proper scoop storage.
Improve the personalization of      Personalize information (e.g., hot
information on risks and benefits.  dog recall, Listeriosis, and the
                                    potential consequence of serving
                                    undercooked hotdogs at the family
                                    picnic).
Improve understanding and specify   Use local examples of restaurant
consequences of the risk.           foodborne-disease outbreaks; cite
                                    risk in serving large populations,
                                    risk of potentially creating
                                    life-and-death health problems,
                                    and bad publicity.
Expand on how-to information,       Use signage for sanitizer and
promote awareness, and employ       handwashing (change signage at
reminder systems.                   least quarterly, to keep reminders
                                    "fresh"), maintain time-
                                    temperature logs, and make
                                    self-assessments of food
                                    stands to evaluate progress.
Expand the identification and       Ideas include a poster contest,
reduction of barriers through       best-inspection-report award, pay
verbal reassurance, incentives,     incentive, plaque, romantic dinner
praise, & rewards; encourage        in the sports lounge.
self-rewards & give assistance.
Increase training and guidance      Involve staff in performing mock
in performing action.               inspections.
Use progressive goal setting.       For repeat offenders, set goals to
                                    help staff be more accountable
                                    (e.g., develop a checklist for
                                    opening a restaurant station).
Improve desired behaviors           One of the most effective methods
through demonstration.              for increasing the adoption of
                                    sustainable behavior is to model
                                    the behavior we wish others to
                                    adopt.
Improve ways to synthesize          Use a newsletter or a weekly
information in ways that have       message system to re-emphasize key
meaning and appeal to your          food protection points. Provide
audience.                           information that takes little
                                    effort to absorb, draws attention,
                                    and is clear.

TABLE 4 Numbers of Violations, by Category, Before and After
Intervention

                         Before Intervention  After Intervention

Number of inspections            166                 281
Nontargeted categories             7                  12
All targeted categories           75                  56
Hot-holding                       16                  11
Handsinks                         24                   8
Ice scoops                        17                  18
Sanitizer                         18                  19
All categories                    82                  68

TABLE 5 Percentages of Inspections with Violations, Before and After
Intervention

                         Before  After  Net Change

Nontargeted categories    4.3%    4.4%    +0.1%
All targeted categories  45.2%   19.9%   -23.1%
Hot-holding               9.5%    4.0%    -5.5%
Handsinks                14.8%    2.7%   -12.1%
Ice scoops               10.0%    6.4%    -3.6%
Sanitizer                11.0%    6.7%    -4.3%
All categories           49.5%   24.2%   -25.3%

TABLE 6 Odds Ratios for Decrease in Actual Number of Violations, by
Category

Nontargeted categories   1.0
All targeted categories  3.3
Hot-holding              2.6
Handsinks                5.8
Ice scoops               1.7
Sanitizer                1.7
All categories           3.1

TABLE 7 Odds Ratios for Decrease in Violation Rates After Intervention

Nontargeted categories   1.0
All targeted categories  3.3
Hot-holding              2.5
Handsinks                6.3
Ice scoops               1.6
Sanitizer                1.7
All categories           3.1

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Terri Jenkins-McLean, R.E.H.S., M.P.H.

Chris Skilton, R.S., M.S.

Clarence Sellers

Corresponding Author: Terri Jenkins-McLean, Sr. Environmental Health Specialist, Community Environmental Health, Public Health-Seattle & King County, 14350 SE Eastgate Way, Bellevue, WA 98007. E-mail: [e-mail].