Characteristics of noncompliant food handling establishments and factors that inhibit compliance in a regional health authority, Jamaica.
The assurance of safe food along the "farm to fork" continuum is an increasing global demand. Food safety regulations are geared towards protecting consumers' health, increasing economic viability, preventing fraudulent practices, harmonizing well-being, and engendering fair trade in foods within and between nations (Garcia Martinez, Fearne, Caswell, & Henson, 2007; Ozekie, 2005; U.S. Department of Agriculture, 1997).
Food safety regulations will only be effective if operators fully understand their benefits, and they are actively reinforced by managerial control with staff playing an integral role (Jones, Parry, O'Brien, & Palmer, 2004). Hence in recognizing the responsibility of industry for the production of safe foods, Tompkin (2001) and Hutter and Amodu (2008) argued that self-regulating systems seem to influence industry in accepting their responsibilities. With state-administered standards, the perception of responsibility for risk management standards is shifted to the regulatory authorities (Fairman & Yapp, 2004) especially if the regulations are deemed to be vague (Genn, 1993). Consequently some operators equate compliance with adhering to instructions given by environmental health officers (EHOs) upon the completion of an inspection (Fairman & Yapp, 2004). Additionally, many operators are ignorant of food safety risks and prefer this prescriptive approach (Henson & Heasman, 1998; Yapp & Fairman, 2004).
Small businesses tend to be less compliant due to the associated costs in attaining and maintaining compliance (Hutter & Jones, 2006; Yapp & Fairman, 2006), which is worst in very competitive markets with small profit margins. Where compliance costs are shared with consumers, however, increased willingness to comply has been observed (Kagan & Scholz, 1984).
Yapp and Fairman (2004) found lack of money, time, experience, access to information, support (from regulators), interest, and knowledge to be primary barriers to compliance. Regarding "lack of access to information" they noted that small- and mediumsized establishments were overwhelmed by the abundance of information as they were unable to determine what was relevant to them. They noted substantial "knowledge" differences between medium-sized establishments and regulators as to what constituted compliance with the former limiting it to conformance with all the requirements made by the EHOs. They also found lack of motivation (99%), lack of trust in the EHOs and their requirements (81%), and lack of management systems (75%) as principal inhibiting factors among medium-sized establishments in the United Kingdom (Yapp & Fairman, 2006).
Numerous other factors adversely impact compliance such as the tendency for EHOs to focus more on urban areas (Hutter, 1988). Additionally, lack of or informal documentation of the registration/compliance procedures, inadequate surveillance activities on the identification of noncompliant establishments, limited assessment of food safety enforcement strategies, failure to inspect all food-handling establishments (FHEs) annually, and poor follow-up of noncompliant establishments have inhibited compliance even when the regulatory framework was deemed appropriate (Auditor General, 2002).
Training of food handlers followed by verification inspections proved effective in reducing infractions related to food handlers' behavior (Averett, Nazir, & Neuberger, 2011) while the introduction of new food safety standards resulted in significant improvements in safe food handling knowledge and practices (Food Standards Australia New Zealand, 2008). Training of restaurant managers was found to positively impact sanitation (Cates et al., 2009; Hedberg et al., 2006). Yapp and Fairman (2004) noted that educational interventions that increased specific food safety knowledge and formal enforcement were among the most effective in improving inspection scores and compliance levels. Fraser and Nummer (2010) found "experience as a trainer" (27%) and "experience working in the retail food service industry" (24%) among the most effective characteristics of an effective food safety trainer, while teaching content using activities and demonstrations (46%) and trainers' experience with the regulations (23%) best enhanced training effectiveness.
Having a good reputation is critical in a competitive food industry (Gunningham, Thornton, & Kagan, 2005). This is so especially where consumers recognize the weight of their purchasing power and the negative impact that published inspection scores and enforcement activities can have on businesses (Thompson, De Burger, & Kadri, 2005), compounded by feelings of shame and even fear of a tarnished image (Parker, 2002). Together these can favorably influence compliance.
In Jamaica, responsibility for food safety is shared among multiple ministries and is a priority program of the Ministry of Health (MOH). The program is primarily administered by public health inspectors (PHIs)/EHOs under the Public Health Act (1974) and Regulations. The primary regulations, the Food Handling Regulations (1998) and the Tourist Establishments Regulations (2000), were promulgated after 1996-1997 when studies revealed a high incidence of diarrhea among visitors to Jamaica. Approximately 74% of visitors from North America who responded to a questionnaire prior to their departure from Jamaica reported experiencing diarrhea (Paredes et al., 2000). Steffen and co-authors (1999) reported on an airport survey of over 30,000 visitors to Jamaica in which the incidence of diarrhea overall was 23.6% while that of classically defined traveler's diarrhea was 11.7%. Swift response by the government of Jamaica resulted in the establishment of a structured national program for the inspection and annual certification of FHEs.
This decisive government action can be readily understood as tourism is extremely critical to Jamaica's economy, accounting on average for 6.9% of its GDP annually for 2007-2012 (Statistical Institute of Jamaica, 2014). It also effectively placed food safety on the national agenda, since prior to 1998 no specific regulations existed governing FHEs. The food handlers' certification program was standardized nationally, training manuals and materials were developed, and applicants were required to attend training sessions and obtain a minimum of 70% in the exam. Similarly, FHEs had to obtain a passing inspection score of 70%, which must include the full score for all the critical items. Regional Health Authorities were expected to attain an FHE certification target of 70% in 2000-2006, 80% in 2007, and 90% since 2008.
The North East Regional Health Authority (NERHA)
NERHA is one of four Regional Health Authorities comprising three of Jamaica's 14 parishes and has 14% (356,000) of the national population. It has a regional food safety officer, three parish food safety coordinators, and 58 EHOs/PHIs, many of whom work in food safety. NERHA has consistently faced challenges in meeting the national targets for certification of FHEs. The aim of our study was to identify and describe noncompliant FHEs in NERHA and to identify the factors influencing their noncompliance.
The study protocol was approved by the ethics committee of the University of the West Indies, Mona. A cross-sectional design was utilized incorporating a mixed-methods approach. For the quantitative component, multistage sampling was used to select 7% (248) of the 3,427 FHEs, which were first stratified by parish and then by health districts. Two health districts were randomly selected per parish. FHEs were randomly selected from each health district to satisfy a predetermined quota. The person-in-charge of each FHE was asked to complete an interviewer-administered questionnaire. Additionally, the most recent food safety inspection report for each FHE was reviewed.
The qualitative component involved two focus group discussions involving 15 participants, one comprised of owners/operators from compliant FHEs who were selected from the zone with the highest certification status and the other comprising noncompliant operators from the zone with the lowest compliance rates. Additionally, key informant interviews were conducted with key administrators of the food safety program.
Quantitative data were analyzed using SPSS (version 16.0). Descriptive statistics such as mean, mode, median, and variance were generated and reported. The differences between respondents of compliant and noncompliant establishments and the establishments themselves were determined by Chi-square analyses while logistic regression was used to identify the factors that were predictive of compliance.
The framework approach was used to analyze qualitative data, which were summarized and grouped under specific themes.
Sociodemographic and Employment Characteristics of Respondents
Two hundred and thirty-two persons-in-charge of FHEs participated, giving a response rate of 93.5%. Respondents were primarily females (71.1%), had a mean age of 43.4 [+ or -] 10.7 years with 38% being 39 years or younger and secondary education (61.2%) being the highest level attained by most. Just under 87% owned and managed the FHEs with 34.5% reporting having worked in the industry for more than 10 years. Fifty-four percent were from urban areas (Table 1).
While substantially more FHEs were compliant (69.4%), noncompliant establishments differed significantly from compliant only in the educational status (p < .05) and possession of a valid food handlers' permit (p < .001) by the person-in-charge. Noncompliant FHEs employed more females (69%) than males (31%) and were more likely to employ persons aged 40 years and older or report primary education. Persons-in-charge of noncompliant establishments were more likely to have been working in the industry for less than 10 years while those of compliant establishments were more likely to have worked in the industry for 10 or more years. Approximately 60% (38) of respondents from noncompliant establishments demonstrated correct knowledge of the compliance process despite 95.8% (68) reporting that they did (Table 2).
Apart from the mandatory food safety training obtained at the health departments' food handlers' training sessions, only 8% (18) of all respondents indicated having additional food safety training. Training was reportedly received in hazard analysis and critical control points (HACCP) and food and beverage management. While 92% (213) reported having been issued a food handlers' permit, only 57.8% (134) were valid. Respondents from compliant FHEs were more likely to have a valid food handlers' permit than their counterparts from noncompliant FHEs (p < .001). Also, respondents in rural areas were more likely to have valid food handlers' permits than their urban counterparts (p = .015).
Significantly more noncompliant FHE were found in urban areas (67.6%) than rural (32.4%) (Table 3). Approximately one-half of these establishments were in operation for five or fewer years and 78.9% operated with three or fewer workers. The majority of respondents reported inconsistent compliance with instructions issued by PHIs, with only 14.1% reportedly complying all the time.
Approximately 54% of noncompliant establishments had not applied for renewal of licenses despite the licenses of 24.3% having been expired for more than six months prior to the survey. Among the establishments that had not applied for licenses, newer establishments (five years or less in operation) were more likely not to have applied while a few establishments (4.6%) had never applied.
Variables that were statistically significant on univariate analysis as associated with noncompliance were entered into logistic regression to determine their association with compliance. Only location, however, was found to be associated with compliance as urban establishments were less likely to be compliant than rural establishments (odds ratio [OR] = 0.45, 95% confidence interval [CI]: 0.25-0.81).
Factors Inhibiting Compliance
The factors inhibiting compliance were categorized as social, economic, and regulatory (Table 4). Forgetting to apply for a license (61%) was the primary social factor inhibiting compliance followed by the lack of time to correct infractions (15.3%) and the lack of time to make application (15.3%). The lack of money to correct infractions cited by the PHI (46%) and lack of money to pay for the license (35.9%) were the two economic factors that inhibited compliance. A significant difference occurred between compliant and noncompliant FHEs in relation to ability to pay for the license (p = .01). Respondents from compliant FHEs were more likely to afford the cost for the license. The lack of understanding of recommendations made by PHI to correct infractions (32.9%) and inconsistencies in PHIs' recommendations (30.7%) were the major regulatory factors cited. Respondents from compliant FHE were more likely to understand PHIs' recommendations (p = .02).
Focus Group Discussions Focus group discussions explored reasons for noncompliance and related program management issues. No member of the two focus groups was able to identify the correct regulations governing FHEs. Typical responses were "oh.... Bureau of Standards ...," "....the health department ...," and "consumer protection agency." All but one participant, however, demonstrated good knowledge of the registration process and all agreed that each establishment should meet public health standards before receiving a license. Regarding the value of compliance, one operator of a certified restaurant responded, "I think it is good. for the owner and the consumer." Some indicated that complying gave them self-satisfaction and confidence to conduct business with pride, as compliance was deemed an asset in attracting customers.
The majority lacked understanding of how FHE inspections were scored, and all indicated that all food safety practices were equally important. The approach to the prioritization of corrective measures to be implemented was that those that could affect the health of the consumers should be given priority treatment followed by those that were very conspicuous. All participants from compliant establishments reported that they relied on the PHI/ EHO to advise on the requirements for the attainment and maintenance of compliance. This was aptly described by a female operator of a certified restaurant: ".... my inspector tells you exactly what is expected of you ..."
Participants identified double standard, bias in targeting compliant establishments, inconsistencies, and lack of adequate monitoring as PHI/EHO-related barriers to compliance. Some participants also indicted the health department for ineffective management of the licensing process, stating that PHIs/EHOs sometimes serve notices for failure to reapply when the license was still in force or for closure when no outstanding infractions existed.
Key Informant Interviews
Interviews were held with the three parish food safety coordinators and the regional food safety officer to determine initiatives implemented to enhance the registration and certification process. These included extensive sensitization meetings, media campaigns, a regional survey to determine the number of operating FHEs, and the reasons for the low rate of application. In direct response to the findings of the survey, decentralization of the application registration centers, increased provision of monitoring tools for the PHIs, and the instituting of the triplicate inspection forms (whereby a copy was left at the establishment for the guidance of the person-in-charge) occurred. One coordinator reported hosting an annual seminar for persons-in-charge of FHEs that enhanced compliance levels, while all interviewees reported that the issuing of closure notices especially at the initial stages increased application rates. As one interviewee reported, ".when you close them, at that time you will find that they comply ... that's what they usually do...."
Regarding noncompliance, they noted that some PHIs did not do follow-up on a timely basis or that "... standards are not equally applied across the board...." and as one interviewee indicated, "there is too much leniency on the part of some PHIs...." All key informants opined that retroactivity should be available in the renewal of licenses such that operators will be penalized for any period for which they had failed to apply. Concern was also expressed about the currency of the existing information management system that had resulted in embarrassment for health departments that had erroneously issued closure notices to licensed establishments that were not in breach. Some operators reportedly made good efforts to receive the license that was not subsequently maintained.
The survey was carried out by PHIs and respondents could have deliberately withheld information relating to compliance due to fear of reprisals.
About one-third of noncompliant FHEs tended to be newer, with the majority located in urban areas. This contrasts with other studies that argued that compliance is usually greater in urban areas as enforcers tend to be more lenient in rural areas as they get to know the people well and fear negative consequences in their relationship with them (Black, 1971; Hutter, 1988, 1997; Hutter & Amodu, 2008). The better compliance among rural FHEs in NERHA, however, could simply be due to their recognition of the potential adverse impact on business in a rural setting if word gets around about enforcement action(s).
Food safety training in NERHA needs urgent attention as it is mostly limited to that received at food handlers' clinics, which only last for 60-90 minutes and are limited in both coverage and depth. NERHA could target managers and supervisors in FHEs for a comprehensive trainer-of-trainers food safety program. The efficacy of this approach in ensuring compliance in FHEs is well established (Cates et al., 2009; Hedberg et al., 2006). This could result in a better trained workforce in FHEs and lessen the pressure on NERHA in affording greater concentration by PHIs on compliance-related issues. If NERHA were constrained in doing so then it could consider the divestment of this aspect of food handlers' training to a competent agency that should provide more in depth and category-specific training. NERHA would retain the responsibility to certify food handlers and PHIs would have more time to concentrate on the certification process inclusive of the maintenance of an effective information management system.
Several barriers to compliance were identified in our study that can be categorized as social, economic, and regulatory (Canadian Food Inspection Agency, 2013). Lack of money, time, and interest as barriers to compliance have also been identified by Fairman and Yapp (2004), Yapp and Fairman (2006), and Canadian Food Inspection Agency (2013). Smaller FHEs may lack the financial and technical resources to understand the requirements (Grabosky & Braithwaite, 1986; Hutter & Jones, 2006) and therefore can experience difficulties in complying (Hutter & Amodu, 2008). Compliance costs can be onerous especially on small establishments hence efforts could be made to assist them to determine such costs and their impact on these small businesses.
Interestingly, some respondents inferred that some PHIs were themselves barriers to compliance describing their recommendations as "unreasonable," "inconsistent," and expressed their lack of understanding of them. Similar findings were reported in the Auditor General's report (2008) and Yapp and Fairman (2004). Since no member of the focus groups was able to identify the correct food safety regulations, it is quite possible that respondents were also not aware of the regulations governing their businesses, which could perhaps explain their reliance on PHIs. Yapp and Fairman (2004) found similar reliance on EHOs for instructions about the correction of infractions and interpretation of the regulations by small- and medium sized establishments. Operators should be encouraged to procure the regulations and understand the requirements for compliance and reduce their reliance on PHIs. The majority of respondents from noncompliant FHEs accused PHIs of not following up on noncompliance issues and this could have led them to conclude that the health departments were not serious about compliance. Similar findings were reported in the Auditor General's report (2008). PHIs charged with enforcing food regulations must demonstrate their seriousness quite unambiguously so that the wrong signals are not sent to FHEs, which could cause them to lose confidence in the regulatory process and undermine its credibility. Operators' forgetting to, or not having the time to, apply for a license or to implement corrective actions is suggestive of the need for enforcement. PHIs must be mindful of this very important option in securing compliance among the deliberately noncompliant, lest they be deemed to be barriers to compliance as was insinuated. Simple precursory measures, however, such as providing operators with a checklist and providing timely reminders about outstanding compliance requirements and deadlines should be explored.
Interestingly, the focus groups identified several barriers to compliance related to PHIs, which mirrored sentiments expressed by respondents such as inconsistency, failure to monitor, and follow-up. They also accused PHIs of bias and double standards. PHIs interviewed were also critical of some of their peers for not doing follow-ups on a timely basis and being too lenient with some clients.
Conclusion and Recommendations
The issues relating to noncompliance are related to social, economic, and regulatory factors involving both the regulated and the regulator. Where breakdowns and/or weaknesses exist in compliance, the public is at risk of foodborne illnesses. Considering that NERHA is one of Jamaica's most popular tourist destinations, foodborne disease outbreaks involving tourists could be disastrous to the country's delicate tourism sector. NERHA should promote greater understanding of the food regulations and a more proactive approach to compliance. Owners/operators of FHEs should be encouraged to assume greater responsibility for the certification of their establishments and NERHA should hold PHIs more accountable for the certification of FHEs. The implementation of an expanded program for the training of food handlers involving a public/private partnership is proffered as well as the implementing of a grading system for restaurants and hotels and the publication of inspection scores together with retroactivity in licensing.
Corresponding Author: Norbert Campbell, Lecturer, Department of Community Health and Psychiatry, Faculty of Medical Sciences, The University of the West Indies, Mona, Kingston 7, Jamaica, West Indies. E-mail: email@example.com.
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Norbert Campbell, MPH
University of the West Indies, Mona
Jeffericia Johnson, MPH
University of Technology, Jamaica
Henroy Scarlett, MPH, DrPH
University of the West Indies, Mona
Sylvanus Thompson, MSc, PhD
Toronto Public Health
TABLE 1 Characteristics of Person-in-Charge of Food Handling Establishments Characteristics % # Total 100.0 232 Gender Male 28.9 67 Female 71.1 165 Age group (yrs.; mean: 43.4 [+ or -] 10.7; range: 20-73) 20-29 10.0 23 30-39 27.7 64 40-49 32.9 76 >50 29.4 68 Education Primary/all age 26.7 62 Secondary 61.2 142 Tertiary 12.1 28 Person-in-charge Owner and manager 86.6 201 Manager 6.5 15 Supervisor 6.9 16 Years working in food service industry [less than or equal to] 5 35.0 81 6-10 30.6 71 >10 34.5 80 Status of food handlers' permit Valid 62.9 134 Invalid 37.1 79 Location Urban 54.3 126 Rural 45.7 106 TABLE 2 Characteristics of Respondents by Compliance Status of Food-Handling Establishments (FHEs) Noncompliant Compliant p-Value Characteristics FHEs % (#) FHEs % (#) Compliance status 30.6 (71) 69.4 (161) NS (c) Gender NS Male 31.0 (22) 28.0 (45) Female 69.0 (49) 72.0 (116) Age (years) (3) NS 20-29 8.5 (6) 10.6 (17) 30-39 21.1 (15) 30.6 (49) 40-49 40.8 (29) 29.4 (47) [greater than 29.6 (21) 29.4 (47) or equal to] 50 Education <.05 Primary/all age 33.8 (24) 23.6 (38) Secondary 57.7 (41) 62.7 (101) Tertiary 8.5 (6) 13.7 (22) Person-in-charge NS Owner and manager 91.5 (65) 84.5 (136) Manager/supervisor 8.5 (6) 15.5 (25) Number of years working NS in food service industry [greater than 36.6 (26) 34.2 (55) or equal to] 5 6-10 31.0 (22) 30.4 (49) >10 32.4 (23) 35.4 (57) Status of food handlers' <.001 permit (b) Valid 46.9 (30) 69.8 (104) Invalid 53.1 (34) 30.2 (45) Additional food NS safety training Yes 7.0 (5) 8.1 (13) No 93.0 (66) 91.9 (148) Understanding of the NS compliance process Self-reported 95.8 (68) 91.3 (147) Established from 55.9 (38) 79.6 (117) knowledge test (a) 1 case missing. (b) 19 cases missing. (c) NS = not significant. TABLE 3 Characteristics of Noncompliant and Compliant Food Establishments Noncompliant Compliant Establishments Establishments Variable % (#) % (#) p-Value Location <.007 Rural 32.4 (23) 51.6 (83) Urban 67.6 (48) 48.4 (78) Type of establishment NS (a) Food/snack shop 66.2 (47) 66.5 (107) Restaurant 22.5 (16) 22.4 (36) Supermarket 11.2 (8) 11.2 (18) Years in operation NS [greater than or equal to]5 53.5 (38) 50.9 (82) 6-10 23.9 (17) 29.8 (48) >10 22.5 (16) 19.3 (31) Size of workforce NS [greater than or 78.9 (56) 68.3 (110) equal to] 3 workers 4-5 workers 11.3 (8) 9.3 (15) 6-10 workers 5.6 (4) 11.2 (18) [less than or equal to] 11 workers 4.2 (3) 11.2 (18) Person-in-charge NS Owner and manager 8.5 (6) 84.5 (136) Manager/supervisor 8.5 (6) 15.5 (25) Compliance with recommendations given by health department NS All of the time 14.1 (10) 28.6 (46) Most of the time 50.7 (36) 49.1 (79) Sometimes 33.8 (24) 21.7 (35) Seldom 1.4 (1) 0.6 (1) (a) NS = not significant. TABLE 4 Factors Inhibiting Compliance Among Food-Handling Establishments (FHEs) Compliant Inhibiting Noncompliant FHEs Total p- Factors FHEs % (#) % (#) % (#) Value Social Lack of time to 23.0 (14) 20.0 (23) 15.3 (37) NS (a) correct infractions (n = 176) Lack of time to make 15.8 (9) 14.9 (11) 15.3 (20) NS application (n = 131) Lack of interest (n 8.2 (5) 14.8 (17) 12.5 (22) NS = 176) Problems with 6.6 (4) 4.3 (5) 5.1 (9) NS workmen (n = 176) Did not remember to 49.1 (28) 70.3 (52) 61.0 (80) NS apply for license (n = 131) Application process 7.0 (4) 4.1 (3) 5.3 (7) NS deemed a waste of time (n = 131) Did not remember to 1.6 (1) 3.5 (4) 2.8 (5) NS implement recommendations made by public health inspector (PHI) (n = 176) Economic Lack of money to 54.1 (33) 41.7 (48) 46.0 (81) NS correct infractions cited by PHI (n = 176) Lack of money to pay 42.1 (24) 31.1 (23) 35.9 (47) .01 for the license (n = 131) Regulatory Did not understand 44.3 (27) 27.0 (31) 32.9 (58) .02 recommendations made by PHI to correct infractions (n = 176) Utilized 30-day 31.6 (18) 23.0 (17) 26.7 (35) NS grace period (n = 131) Inconsistencies in 31.1 (19) 30.4 (35) 30.7 (54) NS PHIs' recommendations (n = 176) PHI did not provide 15.8 (9) 23.0 (17) 14.8 (26) NS reminder (n = 176) No follow-up by PHI 9.8 (6) 13.0 (15) 11.9 (21) NS (n = 176) Did not implement 0.0 (0) 6.1 (7) 4.0 (7) NS recommendations to correct infractions as the health department is not strict (n = 176) (a) NS = not significant.
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|Title Annotation:||INTERNATIONAL PERSPECTIVES|
|Author:||Campbell, Norbert; Johnson, Jeffericia; Scarlett, Henroy; Thompson, Sylvanus|
|Publication:||Journal of Environmental Health|
|Date:||Sep 1, 2015|
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