Food safety knowledge and behavior of emergency food relief organization workers: effects of food safety training intervention.

Introduction

Foodborne illness is a major cause of illness, death, and economic burden in the United States (Food and Drug Administration [FDA], Food Safety and Inspection Service [FSIS], & Centers for Disease Control and Prevention [CDC], 1999). According to CDC (1996, 2001), an estimated 76 million cases of foodborne illness occur each year in the United States, with the annual economic impact estimated to be between $6.5 billion and $34.9 billion (FDA, U.S. Department of Agriculture, U.S. Environmental Protection Agency, & CDC, 1997). It is estimated that each year 325,000 to 500,000 people are hospitalized as a result of foodborne illness in the United States and that at least 5,000 people die as a result of foodborne illness (CDC, 2001; FDA, FSIS, & CDC, 1999; Mead et al., 1999; Taege, 2002). In addition to pathogens that cause acute illness, microorganisms have been identified that can cause chronic illness (Lindsay, 1997; U.S. Department of Health and Human Services [USHHS] Public Health Service, 2000).

Foodborne illness continues to be a concern for several reasons. These include emerging pathogens, improper food preparation and storage practices among consumers, insufficient training of food workers, an increasingly global food supply, and an increase in the number of people at risk because of aging and compromised capacity to fight foodborne illnesses (USHHS Public Health Service, 2000).

Lack of education is also cited as an issue related to food safety. Home economics-type courses are not mandatory for students in school. Thus, safe food storage and preparation methods are not routinely taught (Taege, 2002). In many areas of food service, formal food safety courses are not mandated for all food workers. The food industry has high rates of turnover, which adds to the challenge of educating food workers (Almanza & Nesmith, 2004).

Food safety poses greater risk among specific groups of people. An increased number of people are at risk for foodborne illness because of a compromised ability to fight illnesses. The very young, the very old, pregnant women, and people who are ill are among those more susceptible, and they experience the most severe complications and outcomes as a result of foodborne illness. These high-risk groups represent approximately 20 percent of the American population (Smith, 1997). These people may become ill from smaller doses of microorganisms and may be more likely to die of foodborne illness than are people not in these compromised groups.

Socioeconomic factors and education level have also been identified as issues affecting food safety. While representative research data specific to racial or socioeconomic groups are limited, a report from the United Kingdom indicates a relationship between socioeconomic status and foodborne illness. The report found that hospital admissions for gastrointestinal infection rose with increasing socioeconomic deprivation (Olowokure, Hawker, Weinberg, Gill, & Sufi, 1999).

Food safety is particularly critical in emergency food programs such as food pantries, soup kitchens, and emergency shelters. Emergency food programs distribute food to a significant number of people who are particularly susceptible to foodborne illness. The Hunger in America study (Kim, Ohls, & Cohen, 2001) found that at least half of the participants receiving emergency food nationwide through America's Second Harvest fell into high-risk categories. About one in 10 were elderly, and close to 40 percent were children. Of the emergency food participants in New York State receiving food through America's Second Harvest, 13.6 percent were elderly and 37.6 percent were children. Among emergency food participants surveyed in New York State, about one-third were reported to be in poor health (Kim et al., 2001).

Besides the high-risk status of participants, emergency food programs face additional challenges that increase the risk of foodborne illness. The food used in emergency food programs often goes through many hands before being consumed. Donated food may travel to many points before being transported to a pantry, soup kitchen, or shelter where the food is stored or prepared before being distributed to the consumer. If the product has not been transported or stored properly during any of these transitions, foodborne illness could result. The more points a product moves through before distribution, the greater the risk of foodborne illness.

In addition to the increased risks associated with donated food, emergency food worker food safety knowledge and behavior are of great concern because of the high-risk behaviors of the populations served. Emergency food program workers provide food to participants with limited resources who may practice behaviors that put them at additional risk for foodborne illnesses. Kempson, Keenan, Sadani, Ridlen, and Rosato (2002) identified practices that included eating other people's leftovers and eating meat found as road kill. Leftover food from churches, soup kitchens, nutrition education classes, and senior-dining sites was taken home for later consumption. In some cases, perishable food was not refrigerated. Often, food was stored in jars and placed on windowsills when refrigerators were unavailable. Eggs were left sitting out at room temperature (Kempson et al., 2002).

Low-income populations utilizing emergency food services often lack transportation. Therefore, food may be carried home in hot weather, leaving it without refrigeration for long periods of time. Lack of refrigeration, electricity, and food thermometers may pose risks among this population as well (Scheule, 2004). Thus, it is important that emergency food program workers be knowledgeable about food safety in order to convey food safety messages to participants and to answer food safety questions accurately.

Studies show that consumers in general have inadequate knowledge about the prevention of foodborne illness (Altekruse, Street, Fein, & Levy, 1996). Observational studies of consumer food-handling behavior and knowledge support this finding as well (Haapala & Probart, 2004; Jay, Comar, & Govenlock, 1999). Many consumers feel that they have been cooking for years without ill effects and don't need the hassle of food safety precautions. Consumers tend to rely on the color of meat and intuition rather than thermometers to test doneness. Knowledge of, use of, and enthusiasm of consumers for thermometers have been found to be low (Koeppl, 1998).

Approximately three-quarters of the estimated 76 million cases of foodborne illness are thought to be the result of mishandling by food workers (CDC, 2000). Most documented outbreaks of viral foodborne illness are traced back to a food handler, rather than to industrially processed foods (Koopmans & Duizer, 2004). Of reported cases of foodborne illness in the United States, more than 90 percent were a result of poor food-handling practices involving improper holding temperatures and poor personal hygiene. All were associated with food services or consumer kitchens (CDC, 2000). Research has shown that food workers often lack safe food-handling knowledge, specifically related to temperature control, hygiene, and sanitizing (Burch & Lawyer, 1991, Manning & Snider, 1993).

Proper food safety practices are crucial to the health of emergency food recipients. Emergency food worker responsibilities often include evaluating, transporting, storing, and preparing potentially hazardous foods to a high-risk population. Most emergency food programs that provide delivery utilize volunteers and their personal vehicles. Food transportation can be a safety issue due to sanitation of the vehicle, temperature, and time (Mathieu, 2002).

There has been limited evidence in the literature that safe food handling is adequately addressed in community settings (Lindeman, 1991). Walter, Cohen, and Swicker (1997) found that high percentages of community food workers lacked knowledge of safe temperatures and safe cooling practices, and less than 30 percent of community workers had ever attended a food safety workshop. Also, emergency food programs utilize a large number of volunteers. The Hunger in America study (Kim et al., 2001) found that 93 percent of pantries, 94.6 percent of kitchens, and 66.8 percent of shelters in New York State used volunteers. Many programs relied entirely on volunteers; 60.8 percent of pantries and 48.9 percent of kitchens had no paid staff. Although some volunteers come from a food service background, it is unlikely that the majority of volunteers would have had appropriate food safety training. Volunteers also have a higher turnover than paid staff.

Limited research has been conducted that specifically relates to workers in emergency food programs. Studies of workers in small community settings, however, indicate knowledge deficits in food safety and sanitation (Walter et al., 1997). Food safety education is essential in reducing cases of foodborne illness, particularly among those at the highest risk for foodborne illness. Research suggests that food safety training with an examination has a positive effect on sanitation in food service establishments (Almanza & Nesmith, 2004). Providing a food safety training workshop has been found to be significantly better than providing a food safety manual alone (Soneff, McGeachy, Davison, McCargar, & Therien, 1994).

A study by Gettings and Kiernan (2001) validates previous research emphasizing the important role that educators can play in food safety education and extends the implications to the high-risk population. Although knowledge is not always positively correlated with behavior, sufficient knowledge pertaining to behavior should be provided so that people can make informed choices about food safety practices. Hillers, Medeiros, Kendall, Chen and DiMascola (2003) ranked food-handling behaviors on the basis of risks from specific pathogens. A summary of the top-ranking behaviors includes proper hot- and cold-holding; using a thermometer; dressing cuts and burns on hands before food is handled; avoiding foods that contain raw eggs; avoiding raw or undercooked seafood; sanitizing utensils, cutting boards, and surfaces; washing hands after use of the toilet, after changing a diaper, and before handling food; and, if one is in a high-risk category, avoiding soft cheeses, smoked seafood and pate, and cold deli salads.

Food safety education can benefit both workers and food recipients. Walter and coauthors (1997) suggest a train-the-trainer approach that provides flexibility to accommodate the needs of different learning and skill levels. Trainers can adapt materials as needed. This format allows emergency food program workers to learn safe-food-handling information for their work in the emergency food program, and to pass the information along to other workers, as well as to food recipients. High turnover of emergency food workers makes consistent, ongoing training and refresher courses necessary to ensure improved food-handling practices (Mathieu, 2002).

Understanding the baseline food safety knowledge and practices of emergency food service workers is crucial for the development of effective educational programs. The study reported here investigated food safety knowledge and behaviors of emergency food service workers before and after training.

Methods

Population

The study was conducted in emergency food relief organizations (food pantries, soup kitchens, emergency shelters) in the 10-county region surrounding Rochester, New York, in June 2003 through June 2004. The target group consisted of 276 workers who distribute food through food pantries, soup kitchens, and emergency shelters throughout the region. The majority, 62 percent of these workers, were volunteers with limited or no prior training in food safety. The participants ranged in age from 18 to 74 (mean 55.4) years; 57 percent were female. Fifty-four percent had completed high school, and years of education ranged from five to 19 (mean 12.3).

Sampling Method/Research Design

The researcher utilized a convenience sample of participants in food safety trainings for emergency food relief organization workers. Participation in training was voluntary, but some participants may have been directed by their program director to attend. A pre-test/post-test design was utilized. Eligibility depended on the following criteria: Participants were English speaking and reading, were currently serving as food workers at a food pantry, soup kitchen, or emergency shelter in the 10-county region, and were completing one of 13 food safety training sessions held between June 2003 and June 2004.

A total of 276 people attended one of the 13 trainings and took part in the study. Attendees were given a multiple-choice pre-test immediately prior to the food safety training. The food safety training was specifically designed for emergency food program workers and included topics such as basic causes and symptoms of foodborne illness, evaluation of the safety of food products, and safe practices and prevention strategies. All participants received the same food safety training given by the same certified instructor. Post-tests were administered immediately following the training.

Instruments

Demographic information was obtained on age, gender, education level, status of the worker as a volunteer or paid staff member, and type of emergency food relief organization. A pre-test questionnaire was created to obtain data on food safety knowledge, perceptions, and behavior prior to the food safety training. A multiple-choice format was based on the food issues most associated with common foodborne-illness-causing pathogens (CDC, 2000; Medeiros, Kendall, Hillers, & Mason, 2001). Questions were related to food safety practices of the individual participant as well as to food safety and nutrition knowledge and perceptions. The questions were reviewed and edited by registered dietitians and food bank nutrition resource managers. A second questionnaire was created for use as a post-test to measure changes in food safety knowledge and perceptions. Questions from the pre-test that were related to food safety knowledge and perceptions were repeated on the second questionnaire.

Procedure

Written approval from the State University of New York College at Brockport Internal Review Board for Human Subjects was received in June 2003. The study began with the first training, held on June 6, 2003. Twelve trainings followed, ending in June 2004.

The researcher administered the pre-test immediately before each food safety training. Participants were told that their participation was voluntary and that participation or non-participation would not affect their receipt of a certificate for completing the training. The confidentiality of the study was emphasized. Participants were told that no attempt would be made to link names with pre-test questionnaires.

Topics covered in the training included basic causes and symptoms of foodborne illness, evaluation of the safety of food products, safe food-handling practices, and prevention strategies. Participants were given referral information for future education and questions.

The post-test questionnaire was administered immediately following each food safety training. Participants were again told that their participation was voluntary, that their responses were confidential, and that their responses would not affect receipt of a certificate for completing the training.

Means and standard deviations were calculated for test scores, which were compared with Student's t-test. Analyses were performed with SPSS 10.0.

Results

Scores from the pre-test (M = 61.9, SD = 20.0) and post-test (M = 84.3, SD = 11.6, t = -8.09, p < .0001) indicated that food safety training had significantly improved participants' knowledge. The mean score of volunteers on both the pre- and post-tests was lower than that paid staff, though not significantly so (Table 1). The pre-test questions most frequently missed related to the proper storage of leftovers (40.6 percent answered correctly) and the use of thermometers to check temperatures of food being held (13 percent answered correctly). Post-test, these scores were 91 percent and 87 percent correct, respectively (Table 2).

Discussion

The Hunger in America study (Kim et al., 2001) found that 93 percent of pantries, 94.6 percent of kitchens, and 66.8 percent of shelters in New York State used volunteers; 60.8 percent of pantries and 48.9 percent of kitchens had no paid staff. In the study reported here, the majority of workers were volunteers, many with limited or no prior food service training. The pre- and post-test scores of the volunteers were lower overall, though not significantly so, than those of paid workers. Overall, pre-test results indicate that the most critical concern is lack of familiarity with the use of thermometers to determine safe food-holding temperatures. Other concerns relate to handwashing practices and egg and meat safety. These gaps are consistent with previous research indicating that consumers have inadequate knowledge about the prevention of foodborne disease (Altekruse et al., 1996; Daniels, 1998; & Jay et al., 1999). Data show that more than 90 percent of reported cases of foodborne illness in the United States are related to poor food-handling practices involving improper holding temperatures and poor personal hygiene (CDC, 2000). In the study reported here, food workers and volunteers demonstrated inadequate knowledge related to food-holding temperatures prior to the training. After the training, knowledge increased significantly.

The study involved volunteer and paid staff members working in emergency food organizations. The results, therefore, should not be generalized to all food service workers. Further, this investigation measured self-reported behaviors, which can be prone to response bias by the participants. The authors also acknowledge the need for further instrument validation through additional testing and observational research. The questionnaire assessed the knowledge of basic food safety. Instruments with stronger reliability coefficients, relevant to specific population groups, should be developed in the future. Follow-up with training participants to assess knowledge and behavior retention over time would be useful as well.

Conclusion

While the authors acknowledge the limitations of the study, the results indicate that there is a need for ongoing, on-site food safety education for workers in emergency food services and that training is an effective way to increase knowledge and behaviors associated with the prevention of foodborne illness. Since many of these sites rely heavily on volunteers, it is crucial that there be ongoing education programs to maintain food safety. This training is particularly important given the high vulnerability of individuals utilizing food pantries and similar services.

TABLE 1

Mean Scores and Standard Deviations on Pre- and Post-tests--Volunteers
Versus Paid Staff

Emergency Food Program Workers  Mean, Pre-test   Mean, Post-test
                                  Scores (SD)     Scores (SD)

Volunteers (n = 171)              58.4 (18.1)      82.2 (12.8)

Paid staff (n = 105)              63.2 (19.2)      85.0 (12.1)

All workers * (n = 276)           61.9 (20.0)      84.3 * (11.6)

* p < .001 (pre- versus post-test).

TABLE 2

Distribution of Correct Answers to Selected Knowledge Questions

Food Safety Concern      Test Item               Pre-test     Post-test
                                                (% correct)  (% correct)

Cross-contamination      Wearing gloves when        76           98
                         working with
                         ready-to-eat foods is
                         important.

Use of food thermometer  It is important to         13           87
                         always use a food
                         thermometer when
                         working with hot
                         foods.

Storage of leftovers     The best way to cool      40.6          91
                         a large pot of
                         leftover soup is to
                         transfer the soup to
                         shallow pans or use
                         an ice bath.

Acknowledgements: The authors wish to thank the Hunger Prevention and Nutrition Assistance Program (HPNAP), of the New York State Department of Health Division of Nutrition, for supporting the food safety training of emergency food relief workers in New York State. HPNAP provides funding to ensure that food is stored, distributed, and served safely to people accessing emergency food services throughout New York State.

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Cristin Finch, M.S.Ed.

Eileen Daniel, D.Ed., R.D.

Corresponding Author: Eileen Daniel, Professor, SUNY College at Brockport, Department of Health Science, Brockport, NY 14420. E-mail: [e-mail].