Survey of Food Handler Training and Knowledge
Environmental Health Supervisor-Buncombe County (NC) Health and Human Services
International Food Protection Training Institute (IFPTI)
Fellowship in Food Protection
North Carolina does not require formal training or certification for food handlers. However, there is a requirement for at least one supervisor or manager position to be a certified food protection manager who has passed a test that is part of the American National Standards Institute (ANSI) accredited program. This study used an in-person survey completed by inspectors during visits to compare the types of training received by food handlers and the effectiveness of their training on their food safety knowledge relating to the five risk factors most commonly associated with foodborne illness. There were 187 surveys completed in Buncombe, Union, and Durham Counties, in North Carolina. The surveys contained 10 questions relating to food safety, with two questions focusing on each risk factor: food from unsafe sources, improper holding temperatures, poor personal hygiene, inadequate cooking temperatures, and contaminated equipment/cross-contamination. Food handlers on average scored 70% on the survey. The average score for the person in charge (PIC), or an individual present who is responsible for the operation at the time of inspection, was higher than the score of a food handler who was not a PIC, 73% as compared to 65% (FDA, 2017). Those who had completed an ANSI-certified food protection manager training had an average score of 74% while those who did not complete the training scored an average of 58%. Recommendations based on the results from the study include focusing educational campaigns on the most commonly missed risk factors. Additionally, agencies should implement risk control plans at food service establishments with a record of non-compliance and consider allocating resources for short classes aimed at increasing compliance along with an ANSI certificate program for food handlers.
Keywords: Foodborne illness, food handler, training
Each year in the U.S. an estimated 48 million people contract a foodborne illness, leading to 128,000 hospitalizations and 3,000 deaths (CDC, 2018a). There were 829 foodborne disease outbreaks reported in 2016. Surveillance data from 2016 concludes that 61% of outbreaks are reported to occur at a single location of preparation such as a restaurant. Restaurants with seating accounted for 48% of the outbreaks reported (CDC, 2018b). US consumers spend 47% of their food dollars in restaurants and restaurants employ more than 9% of the workforce in the U.S. (Jones & Angulo, 2006).
The estimated cost of a foodborne illness can range from $3,968 to $2.6 million, depending on the type of establishment. The lower end projections were based on a 5-person outbreak without any legal action or loss of revenues. The higher projections were based on a 250-person outbreak with a high cost of legal fees, including lawsuits and loss or revenues (Bartsch, Asti, Nyathi, Spiker, & Lee, 2018).
While there are 32 contributing factors identified during the preparation of food that can lead to a foodborne illness, all these factors can fall into one of three types: contamination, proliferation, and survival of pathogens. Contamination occurs when pathogens or other hazards are introduced into the food. Proliferation occurs when pathogens grow in the food and survive when the kill step for a pathogen is not executed with success (CDC, 2017). The Food and Drug Administration (FDA) standardization inspection report focuses on the five risk factors commonly attributed to a foodborne illness. Those risk factors include unsafe sources, improper holding temperatures, poor personal hygiene, inadequate cooking temperatures, and contaminated equipment/ cross-contamination (FDA, 2015).
Currently in North Carolina the relationship between the training obtained by a food handler and their knowledge of food safety is unknown.
- What is the relationship between training and the current knowledge base of food safety in food handlers?
- What opportunities are there for regulators to address the gaps in training?
A questionnaire containing 10 questions relating to the five risk factors most commonly associated with a foodborne illness was verbally administered during routine inspections for Risk Category 3 and 4 food service establishments in North Carolina. Surveys were performed in Buncombe, Union, and Durham Counties. Establishments that fall under a Risk Category 3 are food service establishments that cook and cool no more than 3 potentially hazardous food products. Establishments that fall under a Risk Category 4 are food service establishments that cook and cool an unlimited number of potentially hazardous food products and any establishment that performs a specialized process or serves a highly susceptible population.
Inspectors were asked to administer the questionnaire after completing the inspection. Inspectors informed the operator that the results would not be punitive and there would be no identifying information on the questionnaire. Inspectors were also instructed to administer the questionnaire to a food handler that had the most contact with food and whose duties were mostly centered around food preparation.
The questionnaire was multiple choice with each question having the option of an unsure response. Respondents were encouraged to answer unsure, rather than guess, in order to yield more accurate results. There were two questions targeting each of the risk factors commonly attributed to a foodborne illness. Questions were asked regarding food from unsafe sources, improper holding temperatures, poor personal hygiene, inadequate cooking temperatures, and contaminated equipment/ cross-contamination.
The survey instrument also included a table to be completed by the inspector that collected information pertaining to the type of facility and the training provided by the facility. The information gathered included, the number of risk factor violations observed during the inspection and whether the establishment was a franchise/chain. Data was also collected on the respondent pertaining to the type of training they had received; length of training; whether their training was continuous; and if they had ever received the certified food protection training. Additional information about their positions within the company and years with the company was also collected.
The study found that those who scored 80% or higher were more likely to have passed an ANSI-certified food protection manager test and the establishment would also have written standard operating procedures (SOPs). Nearly 91% of those who scored 80% or higher on the exam had passed an ANSI-certified food protection manager test. Of those who scored 60% or less on the test, 63% had completed an ANSI-certified food protection manager training. The most commonly missed questions were those on inadequate cooking temperatures, inadequate holding temperatures, poor personal hygiene, and approved sources. Questions pertaining to cross-contamination had the highest level of correct answers.
Of the 187 food handlers who were surveyed, 141 reported having on-the-job training while 19 reported having no training during their employment (see Table 1). Table 1 shows the relationship between the training received and the average score on the survey. Those who received training after their initial training and those who received training through videos both had the highest averages on the survey. Of all who were surveyed, 149 reported receiving a certified food protection manger training which includes passing an ANSI-certified food protection manager test.
The research showed that on average food handlers were able to answer nearly 7 out of the 10 questions correctly, scoring approximately 70% on the survey. A breakdown of the scores is illustrated in Table 2. The average score of the person in charge (PIC) who is a food handler was higher than the score of the food handler who was not the PIC (7.3 compared to 6.5). Figure 1 reflects the number of incorrect responses based on each risk factor.
The study methodology was proven to be effective in gathering data due to the cooperation and response rate. The respondents who had completed an ANSI-certified food protection manager training yielded higher results on the survey. The lack of training for some food handlers denotes an opportunity for Environmental Health departments to look at providing basic food safety education geared towards food handlers. Based on the common questions missed, educational campaigns should be focused on proper final cook temperatures for ground meat products, proper hot holding temperatures, personal hygiene, and approved sources.
- Future educational campaigns should be aimed at addressing the risk factors that were commonly missed.
- Agencies should implement risk control plans at food service establishments that are found to have a repeated history of non-compliance associated with one of the five risk factors.
- Agencies should offer assistance to establishments on developing SOPs to facilitate training.
- Agencies should consider allocating resources for short classes aimed at increasing compliance for out of control risk factors relating to foodborne illness for employees involved in the preparation of food.
- Agencies should offer an ANSI certificate program for food handlers.
- Additional research should be conducted to evaluate the factors involved for those who had the ANSI-certified food protection manager training but did not score well on the survey.
I would like to acknowledge IFPTI for awarding me this opportunity and the other Fellows for enhancing the experience and providing support. I would also like to acknowledge Cameron Wiggins and Dona Wanucha, with FDA, for their assistance and guidance. I would like to thank my organization, Buncombe County Health and Human Services for its support and encouragement. However, this project would not have been possible without the work provided by the staff at Buncombe, Union, and Durham Counties.
Bartsch, S. M., Asti, L., Nyathi, S., Spiker, M. L., & Lee, B. Y. (2018). Estimated cost to a restaurant of a foodborne illness outbreak. Public Health Reports 2018 May/Jun;133(3):274-286. doi: 10.1177/0033354917751129
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Jones, T. F, & Angulo, F. J. (2006). Eating in restaurants: A risk factor for foodborne disease? Clinical Infectious Diseases, 43(10), 1324-1328. Retrieved from https://www.jstor.org/stable/4485096
U.S. Food and Drug Administration. (2015). FDA Procedures for Standardization of Retail Food Safety Inspection. Retrieved from https://www.fda.gov/downloads/Food/GuidanceRegulation/RetailFoodProtection/Standardization/UCM472201.pdf
U.S. Food and Drug Administration. (2017). Food Code 2017. Retrieved from https://www.fda.gov/downloads/Food/GuidanceRegulation/RetailFoodProtection/FoodCode/UCM595140.pdf