It all started with a nice Friday evening dinner at a local restaurant. Maybe it was an anniversary or a birthday celebration. Then something bad happened. The part-time busboy, who also is in charge of salad preparation when things are busy, didn’t wash his hands after a trip to the restroom. Then he grabbed some lettuce, tossed it in a bowl with some other veggies and mixed it all. By hand. He didn’t know that the illness he had just gotten over was a norovirus infection and that he was still shedding the virus. The result: 2 or 3 days later, an individual hovering over the toilet, dealing with foodborne illness symptoms at both ends, swearing never to eat at any restaurant again.

Food businesses, especially restaurants, get horrible press for making patrons ill. Even without a definitive connection, there is sometimes a belief that the last meal led to the bout of gastrointestinal distress. While foodborne illnesses do occur at foodservice establishments, it is difficult to quantify how many and to what extent. Despite the lack of data, the foodservice industry, with the partnership of public health, has been proactive in addressing foodborne illness risks within their kitchens. Where things break down is at the implementation stage: if the 14-year-old busboy doesn’t wash his hands or if the 21-year-old line cook cross-contaminates.

The World Health Organization (WHO) reports that up to 30% of individuals in developed countries acquire illnesses from the food and water they consume annually. In line with the WHO, U.S., Canadian and Australian health officials have similar estimates. Foodborne illness is a big problem, and not just from a public health burden. It has been estimated that food-related illnesses cost the U.S. between $152 billion and $1.4 trillion annually. Outbreaks, or even just rumors of illness, are responsible for business closures every year.

Communicating with Food Handlers
In a recent review of foodborne illness outbreaks in foodservice, an international group of food safety researchers reported 816 outbreaks linked to food handler practices, resulting in 80,682 cases of foodborne illness.[1] In the review, nearly 60% of food handler-related outbreaks were due to two specific pathogens often liked to hygiene issues: norovirus and Salmonella.

Despite the investment and focus on training, researchers suggest that the impact of food handler training programs is inconsistent and program evaluation is rarely conducted.

Ideally, food safety in foodservice estab-lishments begins with managers who are knowledgeable about the following:[2]

•    Where contaminants exist

•    How they transfer to food

•    The steps to control or eliminate hazards

In a 2007 study, researchers at Oregon State University explored factors that prevented food handlers from practicing good personal hygiene. Through focus groups, participants reported time pressures; inadequate facilities and supplies; lack of accountability; lack of involvement of managers and coworkers; and organizations not supportive of food safety as barriers to employing good personal hygiene. These aren’t biological issues but communication and organizational issues. Highlighting the importance of communication, one food handler was quoted as saying: “I am very curious. I know germs exist and they are out there. We hear about Salmonella and all that stuff. But I’m curious as to if we don’t wash our hands, what is the result? I think we should be educated because I don’t really know what happens. I mean yeah, you get sick. But what does Salmonella do to a person?”[3]

The U.S. Centers for Disease Control has been recently calling on food safety communicators to design new materials aimed at increasing food safety risk reduction practices from farm-to-fork. This priority was echoed at the Food Safety Inspection Service/NSF food safety education conference in March 2010: new messages and media are needed as the traditional communication tools aren’t getting the job done.

Food Safety Culture
A culture of food safety is built on a set of shared values that operators and their staff follow to produce and provide food in the safest manner. In an organization with a good food safety culture, individuals are expected to enact practices that represent the shared value system and point out where others may fail.[4–6] Using a variety of tools, consequences and incentives, businesses can demonstrate to their staff and customers that they are aware of current food safety issues, that they can learn from others’ mistakes and that food safety is important within the organization. Creating a culture of food safety within a business means supporting an environment where staff know the risks and how to manage them, and where they value not making patrons ill. A food safety culture requires application of the best science with the best management and communication systems, including compelling, rapid, relevant, reliable and repeated messages (read sidebar What Works in Communicating Food Safety).[7]

That’s where food safety infosheets come in.

Food safety infosheets are one-page posters, built around a current food safety issue or outbreak, supplemented with graphics and prescriptive information targeted at the food service industry (food handlers and business operators). The infosheets are used to provide food safety risk-reduction information to generate behavior change and support a food safety culture. Over 150 examples since 2006 can be found at www.foodsafetyinfosheets.com.

The idea was to take recent foodborne illness-lined media coverage and relevant research and give them to food handlers. At first, they were text heavy, boring and weren’t very good. After a couple of years of refinement—fed by intense work with the target audience through multiple experiments (including washing dishes in a commercial kitchen)—food safety infosheets have turned into a useful tool. A few foodservice, retail and processing companies have reported building their food safety training regimes around them.

Evaluation of Interventions
While this is all great, what was needed was to determine that food safety infosheets actually worked. Too often, fantastic communication ideas are implemented with no evaluation conducted to confirm whether the tools actually do anything. Surveys, focus groups and other methodologies focusing on behavior change have a place in food safety research, but alone, tell us more about what individuals think than how they act.

As getting at actual food handler actions was difficult, we used video observation to capture these food safety actions so they could be measured pre- and post-exposure to the food safety infosheets. Observation is awesome because practices aren’t viewed through a filter. Video observation is more awesome because individual actions can be stopped, rewound, slowed down and viewed by multiple people from multiple angles. Using video observation to evaluate any behavior change that the infosheets might create became the focus of a 3-year project.[8]

After striking up a relationship with a major international foodservice company around the use of infosheets, their extremely open and progressive food safety manager allowed our team into their kitchens with our macbooks and webcams, let us ask their employees for permission to record them working, and we were off. In a true demonstration of a good food safety culture, the company wanted to know how well their training programs and other tools (like the info-sheets) might be working. No one expressed concern over what we might see, they wanted to know where they should concentrate resources.

We recorded 47 employees at eight different sites making meals and snacks for a couple of days. Infosheets were placed in plastic coverings, posted weekly for 7 weeks, and then we went back with our voyeur tools and recorded again. We generated 348 hours of observation data (and about 1 year of video analysis). Participants were on-camera for an average of 13.5 hours of actual food handling pre-food safety infosheet introduction and another 13.5 hours post-infosheet introduction.

During our first observation session, food handlers were recorded demonstrating just over 21 handwashing attempts over the course of 2 days (an average of 1.5 handwashing attempts per hour). However, only about 10% of attempts coded as correct. The most common factor leading to an incorrect handwashing event was the lack of proper hand drying with a paper towel. Many observed participants used aprons or their clothes to dry their hands. Indirect cross-contamination, where a food contact surface such as a cutting board or a utensil was contaminated with a raw food or dirty hands and then was used with a ready-to-eat food, occurred close to once per hour.

The infosheets worked. After being exposed to the weekly postings, cross-contamination events went down and handwashing attempts went up. While significant improvements were seen, a drastic improvement or elimination of risky practices was not.

The prevalence of indirect cross-contamination seen throughout our study also supports the creation of a good food safety culture—that food handlers act in a multi-user environment but may not see themselves as part of a team. Many of the recorded indirect cross-contamination events occurred when multiple food handlers used common food contact surfaces, utensils or equipment. The team-like nature of a foodservice system is currently missing from some food safety training packages and could in fact become a focus–it’s a way to teach and support food safety culture.

Overall, we found more risky practices in some areas than we expected. Most previous studies relied on inspection results and self-reporting by food handlers to estimate instances of “cross-contamination,” finding that cross-con-tamination was relatively infrequent. We found approximately one cross-contamination event per food handler per hour. We also found that when things are really busy, more mistakes are made (including cross-contamination and poor handwashing). We saw that cross-contamination events can largely be a team issue as many people work on the same meal and use common equipment. Sometimes one person contaminates a cutting board and the next person, minutes later, uses that cutting board for a ready-to-eat food.

Conclusions
Some of the largest foodservice, retail and food processors in the world currently use food safety infosheets on a weekly basis. One company has anecdotally shared that they changed their food safety training to all food safety infosheets, and reported that they know it is effective as employees have been overheard discussing the content, especially the stories, during lunch breaks.

It is not enough to provide prescriptive information to food handlers and expect that it will be followed, especially when recognizing the multiple priorities, and time pressures, encountered in the kitchen system. Food safety information needs to be tailored to specific target audiences. Sanitized, generic, social marketing campaigns created by government and the food industry, aimed at the general workforce, may do little to compel food handlers to change practices. Results of this study suggest that food handlers enjoy stories about the consequences of food safety as well as being presented with control measures realistic for the kitchen environment. A drawback of traditional food safety communication is that it is not built specifically to integrate into to the lives of food handlers to provide a personal context. Food handlers are a varied group with multiple learning styles (which are primarily visual and hands-on), and any tool that is directed at the group needs to utilize different communication techniques including story telling supported with graphics, surprising messages and prescriptive messages. Food safety infosheets are just one tool that can be used to foster a food safety culture within a business. By posting food safety infosheets, businesses can demonstrate that they are aware of current food safety issues, that they can learn from others’ mistakes and that food safety is important within the organization.

Ben Chapman, Ph.D. is an assistant professor and food safety extension specialist at North Carolina State University in Raleigh, NC where he supports extension agents, focusing on consumer, retail and foodservice food safety issues. He has designed, implemented and evaluated on-farm food safety programs, consulted for industry and government around food safety issues and conducted observation studies at foodservice, farmers’ markets and in food production settings. A co-creator of barfblog and publisher of food safety infosheets targeting food handlers, much of his work focuses on telling food safety stories with the aim of enhancing trust and changing behaviors.

References
1.    Greig, J. D., E. C. D. Todd, C. A. Bartleson and B. Michaels. 2007. Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 1. Description of the problem, methods and agents involved. J Food Prot 70:1752–1761.

2.    McSwane, D. Z. and R. Linton. 2000. Issues and concerns for HACCP development and implementation for retail food operations. J Environ Health 62:15–18.

3.    Pragle, A. S., A. Harding and J. C. Mack. 2007. Food workers’ perspectives on handwashing behaviors and barriers in the restaurant environment. J Environ Health 69:27–32.

4.    Griffith, C. J., K. M. Livesey and D. Clayton. 2010. Food safety culture: The evolution of an emerging risk factor? Br Food J 112(4):426–438.

5.    Griffith, C. J., K. M. Livesey and D. Clayton. 2010. The assessment of food safety culture. Br Food J 112(4):439–456.

6.    Yiannas, F. 2009. Food safety culture: Creating a behavior-based food safety management system. New York: Springer Science.

7.    Chapman, B., T. MacLaurin and D. Powell. 2010. Design, re?nement and initial evaluation of food safety infosheets. Br Food J (in press).

8.    Chapman, B, T. Eversley, D. Fillion, T. MacLaurin and D. Powell. 2010. Assessment of food safety practices of food service food handlers (risk assessment data): Testing of a communication intervention (evaluation of tools). J Food Prot 73(6):1101–1107.


Sidebar

What Works in Communicating Food Safety
Telling stories: Multiple studies have shown that messages based on stories, and those that were meant to elicit emotion about individual practices, had more impact on the desire to use safe practices than presenting consequence-based statistics alone. Telling stories about the consequences of foodborne illness, where the receiver can identify with the narrative, is more effective than just a stat.

Generation of surprise: The level of surprise in a message determines how successfully the information is received. In 1948, the Bell Telephone Company commissioned a study on communication as a mathematical theory to aid in the design of telephones—the foundation of the theory is that a message is more likely to be received correctly and effectively if viewed by the receiver as a surprise. Providing trivia/did-you-know-type information or shocking pictures are effective ways to accomplish this.

Context: Putting information into context and creating a personal connection between consequences and daily/common actions increases the likelihood of a message-changing behavior. Focusing on context in message development means creating a connection between the actions that a food worker carries out, specific to their job (whether it be preparation, cooking, etc.), and pointing out where an individual has control over risk reduction—answering the question “What can you do?”

Dialogue: The creation of dialogue—discussion amongst the target audience—can also increase message effectiveness. Organizational behavior research states that creating dialogue and generating discussion between staff is a necessary condition for teamwork and working towards shared values.

(Adapted from 7)