Employee Health Policy Effectiveness in Vermont Retail Food Service Establishments
Andy Chevrefils
Public Health Inspection Manager, Vermont Department of Health
Abstract
Retail food service establishments in Vermont are licensed and regulated by the Vermont Department of Health (VDH). Vermont Regulations for Food Service Establishments are the State’s administrative authority for retail food service establishments. The regulation does not require a specific employee health policy to address ill food service workers, however, the regulation does require an employee to inform a Person-in-Charge if they have any illness, condition, or symptoms that may cause foodborne illness. To date, employee health policy effectiveness in retail food service establishments in Vermont has not been studied. This study deployed an electronic survey to food service employees and managers in randomly selected, licensed food service establishments. The survey was primarily designed to assess the effectiveness of employee health policies, including the level of awareness and implementation. Conclusions derived from data analysis suggest food service employees and managers report to work while experiencing symptoms of foodborne illness. As a result of this study, recommendations for VDH consideration include increasing outreach to food service establishments and workers on foodborne illness symptoms, adopting the current version of the U.S. Food and Drug Administration Food Code, improving assessment of foodborne illness symptoms during inspections, and supporting sick leave policy development to allow workers to be paid when they need to miss work.
Keywords: retail food safety, electronic survey, employee health policy effectiveness, foodborne illness.
Employee Health Policy Effectiveness in Vermont
Retail Food Service Establishments
Background
The Vermont Department of Health has investigated several foodborne illness outbreaks related to food service employees who worked while ill. Department of Health investigations revealed in some cases, employees knowingly worked while experiencing vomiting or diarrhea. Between 2014-2016 over half of foodborne illness investigations reported to the Centers for Disease Control and Prevention (CDC) National Environmental Assessment Reporting System (NEARS), identified at least one contributing factor associated with a food employee who was ill or infectious while working (Lipcsei LE, Brown LG, Coleman EW, et al., 2019). In 2018, 13 laboratory confirmed ill food employees were involved in a norovirus outbreak at a large restaurant in Vermont, where 475 customers reported foodborne illness symptoms after dining at the restaurant. Investigation showed that, while a portion of employees denied having illness symptoms while working, four of the laboratory-confirmed employees reported working while symptomatic with vomiting, diarrhea, stomach cramps, and nausea.
Current Vermont Health Regulations for Food Service Establishments (based on the 2001 U.S. Food and Drug Administration (FDA) Food Code) require employees to report to the Person-in-Charge (PIC) any illness, conditions, or symptoms that might cause any type of foodborne illness (Vermont Department of Health, 2003). The PIC also is required to inform the Department of Health when any food employee is diagnosed with a reportable illness. The rule also outlines certain criteria for exclusion and restriction of employees based on illness or symptoms experienced. The 2017 Food Code requires food employees to be informed, in a verifiable manner, of their responsibility to report to the PIC information about their health and activities as they relate to diseases that are transmissible through food (FDA Food Code 2017). A written employee health policy is not required by Vermont regulations or the Food Code.
As a model, the Food Code provides guidance to food service managers and regulatory officials to ensure exclusion of infected food employees during a time when they are at greatest risk for contaminating food (FDA Food Code 2017). The Food Code Annex provides additional guidance on design and implementation of an employee health policy (FDA Food Code 2017). Furthermore, FDA developed the Employee Health and Personal Hygiene Handbook (FDA Employee Health and Hygiene Handbook 2020). This guidance document provides basic information on the importance of employee health as well as step-by-step guidance for development and implementation of an effective employee health policy.
Though resources are available to industry and regulators, food employees and managers who go to work while ill continue to impede reduction of foodborne illness. Research suggests food employees are under significant pressures to continue to work even though they are feeling ill. Issues related to income, employment status, and feelings of guilt for missing work, all contribute to food service employees continuing to work even though they should stay home to recover (Hsuan C, Ryan-Ibarra S, DeBurgh K, et al., 2017). Many food service establishments have documented employee health policies, but awareness and implementation of these policies by employees and management is unclear.
Previous research coordinated through the Centers for Disease Control and Prevention Environmental Health Specialists Network (EHS-Net) identified deficiencies in food service policies and practices concerning ill food service employees (Sumner S, Brown LG, Frick R, et al, 2011). EHS-Net studies concluded that food service employees, in restaurants without an employee health policy that requires employees to tell managers when they are ill, are more likely to have worked while experiencing vomiting or diarrhea (Sumner S, Brown LG, Frick R, et al, 2011). During food employee interviews in EHS-Net states, almost 20% of respondents said they had worked one or more shifts in the previous year while ill with diarrhea or vomiting (Carpenter LR, Green AL, Norton DM et al., 2013).
Communicating health-related information with a manager may be difficult for some employees. EHS-Net findings revealed that employees decided to work or not work while experiencing illness symptoms and did not include a discussion with their manager to make this decision (Carpenter, L.R., Green, A.L., Norton, D.M. et al., 2013). Managers also may feel uncomfortable asking employees questions related to the employee’s health or may feel that they might violate laws which protect employee health information. EHS-Net findings determined that managers were less likely to specifically ask about diarrhea or vomiting symptoms after they had been notified by an employee that they are sick (Norton, D.M., Brown, L.G., Carpenter, L.R. et al., 2014). Additionally, the same study suggested a small percentage of managers themselves worked while experiencing diarrhea or vomiting. These findings strengthen the importance of clear communication between employees and managers and highlights how managers influence the culture of food safety within the establishment.
Recent events related to the COVID-19 Pandemic adds to the need for comprehensive, consistent, and easy-to-implement employee health policies. New strategies and technologies for successful implementation of employee health policies, and a change in attitude toward employee illness may be a result of new challenges food service establishments are facing as the world works to battle this novel virus.
Problem Statement
Employee health policy effectiveness in Vermont retail food service establishments is not known.
Research Questions
1. How aware are food service employees and managers of employee health policies?
2. What training is provided for employees and managers on employee health policies?
3. What foodborne illness symptoms are employees and manager aware of?
4. Do food workers report to work ill, and if so, how often does this occur?
5. What policies do food service establishments have to support ill employees staying home?
Methodology
Data was collected by deployment of an electronic survey developed with Alchemer (formerly Survey Gizmo). Survey questions were designed to gauge employee health policy awareness, implementation, and effectiveness, by evaluating employee and manager retail food service industry experience, knowledge of employee health policies, familiarity with foodborne illness symptoms, individual habits related to working while ill, and policies that encourage ill food employees to stay home. An open-ended question asking about individual experiences related to employee health was included in the survey. A total of 26 questions were developed for the survey.
Four hundred ninety-five (495) licensed retail food service establishments were selected randomly and contacted by telephone to solicit participation of one food service manager and one employee. If an individual agreed to participate, a text message or email was sent to them with a website link to the electronic survey. Data collected through the survey was analyzed with quantitative and qualitative data tools available on the Alchemer platform as well as Microsoft Excel to identify trends.
Results
Four hundred seventy-six (476) volunteers agreed to participate in the survey. Over a four-week period, 50.1% (239) of volunteers successfully completed the survey. Of all respondents, 79.1% (189) identified as food service managers and 20.9% (50) identified as food service employees. When asked, 72.6% (138) of managers indicated they had completed a certified food protection manager training course. Of workers, 60% (30) indicated they had taken a certified food protection manager or food handler training course.
Eighty-four percent (42) of employees and 90.5% (171) of managers reported either seeing or hearing about the employee health policy at their place of work. Of those respondents, 87.3% (186) indicated the employee health policy at their place work is documented in some manner. Eighty-six percent (148) of managers and 92.9% (39) of employees that had awareness of the employee health policy, indicated they were trained on how to comply with the employee health policy at their job. Of those that identified as a manager, 13.9% (24) indicated they received no training or were unsure if they did receive training. Additionally, 77.9% (148) of managers said they provide training on the employee health policy to employees. Training was primarily provided in person 69% (129) followed by computer-based 41.8% (78). When asked to identify symptoms that are commonly associated with foodborne illness, managers who provided training identified jaundice 31.8% (47), sore throat with fever 20.3% (30) and infected cuts and burns with pus on hands and wrists 16.9% (25) as common foodborne illness symptoms.
When asked about symptoms which are commonly associated with foodborne illness, respondents indicated diarrhea 99.2% (238) and vomiting 93.8% (225), but other foodborne illness symptoms were identified less frequently: jaundice 27.5% (66), sore throat with fever 19.6% (47), infected cuts and burns with pus on hands and wrists 15% (36). Headache, which is not commonly associated with foodborne illness, was identified by 28.8% of all respondents. Table 1 reflects awareness levels of common foodborne illness symptoms for supervisors and employees. When asked about symptoms that require you to stay home according to the employee health policy at their job, 96.2% (205) indicated sore throat with fever, 93% (198) vomiting, 85.9% (183) diarrhea, 76.1% (162) infected cuts and burns with pus, and 57.3% (122) jaundice.
Table 1
Foodborne Illness (FBI) Symptom Awareness by Food Service Managers and Employees
Of all respondents, 16.3% (39) reported working while experiencing one of five foodborne illness symptoms identified in the Food Code. Of these 39, 79.5% (31) identified as a manager or Person-in-Charge and 20.5% (8) identified as food service employees. Table 2 shows the percentage of respondents that indicated working with one of the common foodborne illness symptoms listed in the Food Code. Specifically, 11.7% (28) reported working while experiencing diarrhea, 8.4% (20) sore throat with fever and 4.6 6% (11) vomiting.
Sixty-seven percent (21) of managers who said they had worked while experiencing a foodborne illness symptom indicated completion of a certified food protection manager training class. Seventy-three percent (138) of all managers reported completion of a certified food protection manager training class. Focusing on managers who worked while ill, 64% (20) identified providing employee health policy training to employees; 72% (18) of these managers identified diarrhea as a symptom that requires employees to stay home from work.
Fifty-seven percent (137) of all respondents report being paid if they miss a shift because they are sick. Managers reported being paid (59.3%) more often than workers (50%) if they missed a shift because they were ill. Looking specifically at respondents who reported working while experiencing a foodborne illness symptom, 41% (16) reported being paid if they miss a shift. Twelve percent (6) of those identifying as an employee indicated being worried about losing their job when missing work due to being sick compared to 6.3% (12) of managers. Of all respondents who responded working while experiencing a foodborne illness, 20.5% (8) reported they worry about losing their job due to a missed shift. Eighty-three percent (199) of all respondents indicated feeling supported by their employer when they need to miss work because they are sick. Focusing on only respondents that reported working while experiencing a foodborne illness symptom, 61.5% (24) reported feeling supported by their employer when they need to miss work because they are sick.
Of all respondents, 20.5% (49) indicated they had been asked about their health as related to foodborne illness by their supervisor. Looking specifically at employees who reported working while experiencing a foodborne illness symptom, 100% (8) had never been asked by their supervisor about their health and foodborne illness symptoms. Of managers who worked while experiencing foodborne illness symptoms, only 29% (9) indicated they had ever been asked about their health and foodborne illness. Of all respondents who were asked about their health, 92% (46) were asked before their shift, 26% (13) during their shift, and 10% (5) after their shift.
Conclusions
Although food service managers and food service employees are generally aware of employee health policies, there appear to be gaps in knowledge of common foodborne illness symptoms and how employee health policies are understood and implemented. Training on employee health policies is common, but knowledge and the practices of managers providing training could be improved. Food service managers and employees are most likely to recognize diarrhea and vomiting as common foodborne illness symptoms, but are less likely to identify jaundice, sore throat with fever, and infected cuts and burns as common foodborne illness symptoms.
Findings in this study suggest completion of a certified food protection manager training class appears to reduce the likelihood of a manager reporting to work while ill, though managers and employees are just as likely to work while experiencing a foodborne illness symptom. Diarrhea was the most common foodborne illness reported by those who worked while sick, and diarrhea was generally recognized as a common foodborne illness symptom by all respondents.
Getting paid when missing a shift appears to make a difference as to how a worker decides whether they will work when they are ill. If a worker does not receive paid sick leave, results indicated they are more likely to work through foodborne illness symptoms. Even though awareness of employee health policies was generally good, effectiveness may be diminished when employees cannot be paid when they need to miss work because they are ill.
Communication with supervisors is a big influence on how workers decide to work or stay home when sick. Workers being asked about their health, related to foodborne illness symptoms, appears to influence the decision to stay away from working with food. Food service establishments need to be a supportive environment for staff to be able to call in sick with foodborne illness symptoms and still feel supported by their employer. Support and communication are essential for ensuring proper implementation of an employee health policy.
Recommendations
The findings of this study have identified opportunities in Vermont to reduce foodborne illness. Improvements to training, communication, and regulatory partnerships that emphasize the importance of employee health are needed. For improvements to be successful, The Vermont Department of Health should work with stakeholders to implement the following recommendations:
1. Increase outreach efforts about common foodborne illness symptoms to retail food service establishments and workers. Social media or similar technologies should be explored to expand outreach opportunities.
2. Adopt the current version of the Food Code in Vermont to support a greater emphasis on the reporting of foodborne illness symptoms and documentation of training on employee health policies.
3. Require standardized certified food protection manager training for the person-in-charge at retail food service establishments to emphasize the role of managers; especially communication around employee health in preventing foodborne illness.
4. Improve assessment of foodborne illness symptoms and employee health policy knowledge during inspection process.
5. Support legislation that enhances paid sick leave benefits for food service workers.
Acknowledgments
The completion of this project would not have been possible without support from the Vermont Department of Health and the International Food Protection Training Institute. Specifically, I would like to thank Lori Cragin and Liz Wirsing from the Vermont Department of Health, Environmental Health Division. Brian Collins my mentor and Jerry Wojtala from IFPTI, thank you for your leadership and guidance. The Vermont Department of Health public health inspection team, without your efforts, this project would not be possible—thank you for all your time and enthusiasm for this project. I would also like to thank the other IFPTI mentors, IFPTI staff and all the Cohort IX Fellows for making this such a unique and valuable experience.
References
Carpenter, L. R., Green, A. L., Norton, D. M., Frick, R., Tobin-D'Angelo, M., Reimann, D. W., Blade, H., Nicholas, D. C., Egan, J. S., Everstine, K., Brown, L. G., & Le, B. (2013). Food worker experiences with and beliefs about working while ill. Journal of Food Protection, 76(12), 2146–2154. https://doi.org/10.4315/0362-028X.JFP-13-128
Hsuan, C., Ryan-Ibarra, S., DeBurgh, K., & Jacobson, D. M. (2017). Association of paid sick leave laws with foodborne illness rates. American Journal of Preventive Medicine, 53(5), 609–615. https://doi.org/10.1016/j.amepre.2017.06.029
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Sumner, S., Brown, L. G., Frick, R., Stone, C., Carpenter, L. R., Bushnell, L., Nicholas, D., Mack, J., Blade, H., Tobin-D'Angelo, M., Everstine, K., & Environmental Health Specialists Network Working Group (2011). Factors associated with food workers working while experiencing vomiting or diarrhea. Journal of Food Protection, 74(2), 215–220. https://doi.org/10.4315/0362-028X.JFP-10-108
U.S. Food and Drug Administration. (2020). Employee Health and Hygiene Handbook. https://www.fda.gov/media/77065/download
U.S. Food and Drug Administration. (2017). Food Code 2017. https://www.fda.gov/media/110822/download
Vermont Department of Health. (2003). Health Regulations for Food Service Establishments. https://www.healthvermont.gov/sites/default/files/documents/2016/11/ENV_FL_FoodServiceRegs2016.pdf
Author Note
Andy Chevrefils, Public Health Inspection Manager
Vermont Department of Health
This research was conducted as part of the International Food Protection Training Institute’s Fellowship in Food Protection, Cohort IX
Correspondence concerning this article should be addressed to:
Andy Chevrefils, Vermont Department of Health
108 Cherry Street, Burlington, VT 05401
andrew.chevrefils@vermont.gov
*Funding for this statement, publication, press release, etc., was made possible, in part, by the Food and Drug Administration through grant 5U18FD005964 and the Association of Food and Drug Officials. Views expressed in written materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does any mention of trade names, commercial practices, or organization imply endorsement by the United States Government.