Ethnic-food safety concerns: an online survey of food safety professionals.

Introduction

Americans spend over 46 percent of their food dollars on food prepared away from home in restaurants, delis, cafeterias, and other food service establishments, and that percentage is expected to increase (National Restaurant Association, 2004; Stewart, Blisard, Bhuyan, & Nayga, 2004). A population survey conducted between 1998 and 1999 indicated that 83 percent of respondents reported eating out at least once per week, with 16 percent eating out an average of five or more times per week (Jones, Vugia, Selman, Angulo, & EIP FoodNet Working Group, 2002). As American consumers increasingly eat more food away from home, the extent to which food establishments influence the health and well-being of the nation also increases. Each year from 1993 through 1997, an average of 550 foodborne-disease outbreaks were reported to the Centers for Disease Control and Prevention (CDC), of which approximately 41 percent were attributed to food service establishments (Olsen, MacKinnon, Goulding, Bean, & Slutsker, 2000). Furthermore, results from CDC FoodNet case control studies indicated that consumption of food outside the home was associated with an increased risk of gastrointestinal illness and with specific types of foodborne illnesses (Jones et al., 2002; Shiferaw et al., 2004).

The Food and Drug Administration (FDA) Retail Food Steering Committee recommends that regulatory agencies focus their efforts on reducing the occurrence of the factors most commonly identified by CDC as associated with foodborne-illness outbreaks, including food from unsafe sources, inadequate cooking, improper holding temperatures, contaminated equipment, and poor personal hygiene. FDA has established a goal of reducing the percentage of "out-of-compliance" risk factors by 25 percent by 2010 in institutional food service, restaurants, and retail food establishments (FDA National Retail Food Team, 2004).

It has been reported that a study by New American Dimensions and About Marketing Solutions predicts demand for ethnic foods will increase 50 percent over the next decade, driving annual sales to $75 billion (Howell, 2005). Between 1990 and 2000, there was an increase from 3 to 10 percent in total foodborne-disease outbreaks attributable to ethnic foods, and between 1990 and 2003, contaminated multi-ingredient ethnic foods, such as Italian, Mexican, and Chinese foods, caused 135 outbreaks with 2,593 cases of illness (Center for Science in the Public Interest, 2004; CDC Foodborne Outbreak Response and Surveillance Unit, 2003; Simonne, Nille, Evans, & Marshall, 2004).

The American melting pot simmers with foods from every nation. In many cases, the nation has wholeheartedly embraced ethnic foods, sometimes to the point of considering them mainstream (Roberts, 2003). Some of these foods, however, remain outside the common knowledge of both food safety professionals and consumers. As ethnic foods become increasingly available in food establishments across the United States, food safety professionals are increasingly required to evaluate the safety of foods unfamiliar to them. Furthermore, science-based inspection requirements, and resources and training materials that focus on ingredients, preparation methods, storage, and potential hazards of these foods are not widely available (Simonne et al., 2004).

The study reported here involved an online survey of food safety professionals to identify concerns related to ethnic-food safety. The objectives of the study were to 1) identify the types of ethnic foods with which food safety professionals were unfamiliar and for which they lacked adequate food safety information, 2) describe ethnic-food safety concerns related to food establishments that provide for on-site food consumption (food service establishments) or that have packaged foods intended for home preparation and consumption (retail food facilities), and 3) to describe the resources currently used by food safety professionals to locate information on ethnic foods.

The intention is for food safety professionals to use the results of this study in two ways: 1) to prioritize ethnic foods of concern and 2) to identify the food characteristics (e.g., pH, [a.sub.w], microbial contamination) that need to be understood so that product safety can be enhanced and accessible, science-based educational tools can be developed for ethnic-foods.

Methods

Study Design

A cross-sectional study design was used to collect information about ethnic-food safety concerns. On the basis of the study objectives, a survey was collaboratively developed by representatives of the National Environmental Health Association (NEHA) and the Michigan State University Center for Comparative Epidemiology (MSU-CCE), and was pre-tested by NEHA food safety resource reviewers. The survey was designed to describe the type and location of the health jurisdictions represented by respondents; the types of ethnic foods stored, prepared, and served in the establishments that they inspected (including food service establishments, which provide for on-site consumption of food, and retail food facilities, which provide packaged foods intended for home preparation and consumption); respondents' most important ethnic-food safety concerns; and the ethnic-food educational resources available to them. The survey was formatted to collect data through Zoomerang surveys, an online survey service (Market Tools, Inc., 2005).

The study population included a convenience sample of food safety professionals, environmental health professionals, and health department employees with working e-mail addresses listed in the NEHA membership database, the Foodsafe listserv ([e-mail]), and the Food Safety Network listserv ([e-mail]). A cover letter, which included information about the study, and a direct link to the online survey were e-mailed to potential participants.

Notification of the survey was posted on the NEHA Web site home page, which provided a link to another NEHA Web page with specific information on the ethnic-foods survey and a link to the survey itself. In addition, a survey announcement was placed in the October 2004 issue of NEHA's Journal of Environmental Health and in September 2004 NEHA membership renewal notices. Incentives were provided to promote participation. The first 150 respondents who completed the survey received a NEHA pen, and all who completed the survey received a 10 percent discount at the NEHA online bookstore.

Data Analysis

The survey was made available for online data entry from September 1, 2004, to October 31, 2004. All responses were transferred to Microsoft Excel 2000 and coded for analysis. In some cases, categories were created from listed responses, and sparse categories were collapsed. For some questions, multiple responses were provided, so the percentage of responses may be greater than 100 percent.

Data were analyzed with SAS Version 8.1. The statistical significance of comparisons between groups was assessed with Chi-square analysis (Fisher's exact test) and univariable logistic regression. For all analyses, values with a p < .05 were considered statistically significant.

Results

Study Population

During the study period, a total of 341 food safety professionals, nationally and internationally, completed the online survey (Figure 1, Table 1). Because the data from Zoomerang did not include the total number of attempts to complete the survey, it was not possible to assess the survey completion rate.

Ethnic-Food Types Encountered

Respondents reported a wide variety of ethnic foods being stored, prepared, and served in food establishments within their jurisdictions (Table 2). Significant variations in the types of ethnic foods available in jurisdictions were encountered within geographic regions (Table 3)

Ethnic Foods of Concern

Overall, 226 of 334 respondents (67.7 percent) listed at least one ethnic-food of concern for which they lacked adequate food safety information. A variety of ethnic foods of concern were reported (Table 4).

Ethnic Food-Handling Practices of Concern

Respondents were asked to identify food-handling practices and problems encountered at ethnic food-service establishments and retail food facilities in their jurisdictions (Figure 2). Improper food temperature, cross-contamination, and worker hygiene/illness were indicated at least once for each type of ethnic-food establishment.

Ethnic-Food Information Resources 

Respondents were asked to describe the types of ethnic-food information resources they used (Table 5). Because this question was open-ended, multiple types of responses were received and some responses were used more than once. For example, an entry for www.neha.org was included as both an Internet and a NEHA response.

The sources of information used by local-agency respondents (city, county, district, and township respondents combined) were compared with those used by state/federal-agency respondents (state and federal respondents combined). The local group was found to be more likely to use the state as a resource (37 of 221 [16.7 percent], p = .002, OR = 6.83 [1.60-29.14]) and more likely to indicate that no resources were used or that none were available (32 of 221 [14.5 percent], p = .02, OR = 3.78 [1.12-12.75]). Twelve of 221 (5.4 percent) local-agency respondents cited the use of establishment operators as sources of ethnic-food information, compared with none of the 77 respondents from state/federal agencies (p = .08).

Discussion

Study Population

The online survey was conducted to identify ethnic-food safety concerns among food safety professionals. The use of a Web-based survey format allowed for rapid distribution, response, and data summarization. Because of the nature of the online target population, however, it was difficult to assess the actual rate of response. The survey respondents represented a wide range of jurisdictions and geographic locations consistent with the membership of NEHA, which comprises approximately 4,500 members who practice their profession in the public and private sectors as well as in academia and the uniformed services, with a majority employed by state and local health departments (NEHA, 2005).

Ethnic-Food Types

Respondents inspected a variety of food establishments. Approximately 90 percent of respondents reported Chinese and Mexican/Latin American food establishments in their jurisdiction--types of ethnic food that are becoming mainstream. Furthermore, approximately 50 percent of respondents reported that Thai, Southeast Asian, Indian/Pakistani, and Near/Middle Eastern food establishments were found in their jurisdictions, although foods of these types are not yet considered mainstream. Additional emerging ethnic cuisines were reported in lower numbers. Regionally, significant differences in the types of establishments were found. Along with a variety of ethnic-food establishments, a variety of ethnic foods about which food safety professionals had food safety concerns and for which they lacked adequate food safety information were also identified. Exploration into region-specific risk factors, such as types of food establishments available, types of foods served, inspection standards, and food worker training, may provide insights into variations in the occurrence of specific types of foodborne illness.

The size, distribution, and demographics of the U.S. population affect food consumption patterns and the distribution of foodborne illness. Regional differences in the incidence of laboratory-confirmed bacterial foodborne illness were identified in the United States through FoodNet (Angulo et al., 2002). With projected growth of the ethnic population from 28 percent of the U.S. population in 2000 to 36 percent in 2010, ethnic-food availability and consumption patterns are likely to change, as are patterns of associated foodborne illness (Blisard, Lin, Cromartie, & Ballenger, 2002). It will also be important to consider ethnic-food consumption among mainstream consumers, since mainstream consumers currently are responsible for 75 percent of ethnic-food spending and that percentage is projected to increase (Howell, 2005). Therefore, monitoring of changing population demographics, food consumption patterns, and foodborne illness may assist in the prioritization and distribution of ethnic-food safety information.

It is interesting that the types of foods of most concern to respondents were not necessarily those that were the most common. For example, although Mexican/Latin American foods were the most commonly available foods, few Mexican/Latin American foods were found on the list of foods of most concern. It may be that concern gravitates toward types of establishments or foods that are less commonly inspected and that it is related to unfamiliarity with the food or ingredients rather than specific knowledge of hazards.

[FIGURE 2 OMITTED]

Ethnic-Food Handling

The concerns most commonly cited in relation to ethnic food-handling practices were improper food temperatures, cross-contamination, and worker hygiene/illness. For retail facilities, the most important food-handling concerns were use of foods from unapproved food sources, unlabeled or mislabeled foods, and improper food storage. The ethnic food-handling practices that were of concern to respondents were similar to practices of concern in mainstream foods and consistent with the practices reported by CDC as contributing to foodborne-illness outbreaks (FDA, National Retail Food Team, 2004). Science-based inspection guidelines for ethnic foods are lacking, however, particularly for emerging ethnic cuisines that use ingredients and food preparation processes not commonly found in the United States and with which food safety professionals are not familiar.

In the United States and the United Kingdom, it has been reported that language difficulties and lack of knowledge and understanding of food safety principles are a major barrier to the promotion of food safety (Bermudez-Millan, Perez-Escamilla, Damio, Gonzalez, & Segura-Perez, 2004; Green & Selman, 2004; Rudder, 2005; U.S. FDA, 1995). Although they were not addressing a specific question on the survey, respondents noted the language barrier as an important food safety concern, especially for food service establishments. Within U.S. industries, the food service industry employs the highest proportion of foreign-born workers, and this proportion is expected to increase (U.S. Department of Agriculture Foreign Agricultural Service, 2005). To ensure proper implementation of ethnic-food safety practices, food safety professionals will need to receive education on culturally appropriate inspection practices; that education should include tools to ensure effective communication with food service workers.

Ethnic-Food Resources

Food safety professionals described several different resources used to obtain information about ethnic foods; however, more than 23 percent of respondents did not use any resources to locate information on ethnic food. Most of the resources described by respondents were not specific to ethnic foods or ethnic-food safety practices. Often the resources cited were general--for instance, the FDA Food Code, the U.S. Department of Agriculture (USDA), CDC, and NEHA, among others. Some respondents also noted specific ethnic food-related workshops that they had attended and a desire for more ethnic-food safety information. The perception of the availability of ethnic-food resources varied between the local-agency respondents (county, city, district, and township combined) and the state/federal-agency respondents: Respondents from local agencies were almost four times as likely to specifically cite the absence of resources as were respondents from state/federal agencies. In addition, local-agency respondents cited use of food establishment operators as sources of information on ethnic food, while state/federal-agency respondents did not. Although a variety of ethnic-food resources appear to be available, these resources may not focus specifically on ethnic foods, and they may not be consistently available to all food safety professionals, especially those at the local level.

Conclusion

The results of the study reported here indicate that food safety professionals throughout the United States are encountering a variety of ethnic-food establishments and ethnic foods. Continuing to monitor the occurrence of ethnic food-related illness and its association with regional demography and food consumption patterns will assist in prioritization and distribution of information on ethnic-food safety.

Unfamiliarity with ethnic foods, particularly emerging ethnic cuisines, as well as a lack of guidelines for determining the safety of ethnic foods, may affect the ability of food safety inspections to prevent the occurrence of food-borne illness. Although ethnic food-handling practices of concern are very similar to those for mainstream foods, there is a lack of science-based and culturally appropriate ethnic-food safety resources for food safety professionals, especially at the local level. Therefore, to ensure the safety of ethnic foods for consumers, it will be important to identify unsafe food-handling practices in ethnic-food establishments, develop science-based ethnic-food safety inspection guidelines, and distribute culturally appropriate educational materials for ethnic-food safety inspections.

Acknowledgements: The authors would like to acknowledge the personnel and technical support provided by the Center for Comparative Epidemiology at Michigan State University in East Lansing, Michigan.

Corresponding Author: Whitney A. Mauer, Assistant Professor of Epidemiology, Michigan State University, Center for Comparative Epidemiology, College of Veterinary Medicine, A-109 Veterinary Medical Center, East Lansing, MI 48824-1314. E-mail: [e-mail].

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Whitney A. Mauer, D.V.M., Ph.D.

John B. Kaneene, D.V.M., M.P.H., Ph.D., F.A.E.S.

Vanessa T. DeArman

Cynthia A. Roberts, M.S.

RoseAnn Miller, M.S.

Lawrence Pong, R.E.H.S.

Thomas E. Dickey, R.E.H.S.

FIGURE 1 Respondent Jurisdiction of Responsibility (n = 341)

State/Federal  21%
Other          10%
Local          69%

Local = county, city, township, district agencies.
State/federal = state and federal agencies.
Other = tribal and military agencies, industry, and consultants.

Note: Table made from pie chart.

TABLE 1 Geographic Distribution of Respondents (n = 341)

Geographic Region           Number  Percentage

Midwestern United States    94      27.57
Western United States       47      13.78
Northeastern United States  42      12.32
Southeastern United States  40      11.73
Pacific Northwest           33       9.68
Southwestern United States  30       8.80
New England                 19       5.57
Southern United States      15       4.40
Alaska, Hawaii               9       2.64
Canada                       6       1.76
United States                3       0.88
International                3       0.88

TABLE 2 Types of Ethnic Foods Stored, Prepared, and Served in Food
Establishments in Respondents' Jurisdictions (n = 333)

Type of Food            Number of Respondents  Percentage of Respondents

Chinese                 300                    90.09%
Mexican/Latin American  294                    88.29%
Thai                    192                    57.66%
Southeast Asian (a)     173                    51.95%
Indian/Pakistani        169                    50.75%
Near/Middle Eastern     157                    47.15%
Polynesian (b)           71                    21.32%
Ethiopian                60                    18.02%
Japanese                 45                    13.51%
Korean                   23                     6.92%
African                  23                     6.92%
Eastern European (c)     17                     5.15%
Native American          15                     4.50%
Greek                    13                     3.90%
Caribbean (d)            10                     3.00%
South American            6                     1.80%

(a) Vietnamese, Hmong, Cambodian, Laotian.
(b) Polynesian, Indonesian, Filipino.
(c) Russian, Polish.
(d) Jamaican, Cuban, Caribbean.

TABLE 3 Types of Ethnic Foods Stored, Prepared, and Served in Food
Establishments and Retail Food Facilities, by Geographic Region (n = 333
Respondents)

                   Number of                     Percentage of
Region             Respondents  Type of Food     Respondents    p (a)

Pacific Northwest  33
                                Chinese           78.05         0.01
                                Polynesia         41.46         0.00
                                Japanese          24.39         0.04
                                Korean            17.07         0.01
                                Native American   12.20         0.03
West               46
                                Mexican           97.83         0.03
                                Indian            32.61         0.01
South              15
                                Middle Eastern    75.00         0.03
                                Chinese           95.60         0.04
                                Polynesia          9.89         0.00
                                African           14.29         0.00
Northeast          41
                                Indian            65.85         0.04
                                Middle Eastern    63.41         0.03
Southeast          38
                                Mexican          100.00         0.01
                                Caribbean         13.16         0.01
New England        19
                                Indian            77.78         0.03
                                Thai              83.33         0.03

                                            Odds Ratio
Region             Type of Food     Estimate  95% Confidence Interval

Pacific Northwest
                   Chinese           0.32     0.14-0.74
                   Polynesia         3.12     1.57-6.21
                   Japanese          2.37     1.07-5.25
                   Korean            3.55     1.36-9.25
                   Native American   3.93     1.27-12.15
West
                   Mexican           6.87     0.92-51.30 (b)
                   Indian            0.42     0.22-0.81
South
                   Middle Eastern    3.56     1.12-11.27
                   Chinese           2.96     1.01-8.67
                   Polynesia         0.32     0.15-0.67
                   African           3.87     1.63-9.17
Northeast
                   Indian            2.04     1.03-4.04
                   Middle Eastern    2.13     1.08-4.19
Southeast
                   Mexican          11.86     0.71-196.91 (b)
                   Caribbean         4.83     1.53-15.28
New England
                   Indian            3.61     1.16-11.22
                   Thai              3.90     1.11-13.74

(a) Fisher's exact test p-value (p<.05).
(b) One or less without Mexican.

TABLE 4 Ethnic Foods of Concern for Which Respondents Lacked Adequate
Food Safety Information (n = 334)

Type of Food         Number of Respondents  Percentage of Respondents

Sushi, sashimi       52                     15.57%
Peking duck          26                      7.78%
Balut                14                      4.19%
Gyros                12                      3.59%
Filled pastry/buns   12                      3.59%
Rice cakes           11                      3.29%
Kimchee              10                      2.99%
Ethnic cheeses        8                      2.40%
Whole roasted pigs    6                      1.80%
Pho soup              6                      1.80%
Ceviche               6                      1.80%
Yogurt products (a)   6                      1.80%

(a) Includes three instances of homemade yogurt.

TABLE 5 Ethnic-Food Information Resources Used by Respondents (n = 341)

Type of Resource     Number of Respondents  Percentage of Respondents

Internet             78                     22.87%
FDA                  68                     19.94%
State agencies       46                     13.49%
None/none available  38                     11.14%
CDC                  26                      7.62%
USDA                 26                      7.62%
NEHA                 23                      6.74%
Journals (a)         29                      8.50%
Industry groups      18                      5.28%
Universities         15                      4.40%
Establishments (b)   14                      4.11%
Co-workers           12                      3.52%
County agencies      10                      2.93%
City agencies         7                      2.05%

(a) Trade or scientific.
(b) Food service establishments and retail food facilities.