Author: Pham, Mai T; Jones, Andria Q; Dewey, Catherine E; Sargeant, Jan M; Marshall, Barbara J
Date published: June 1, 2012
In recent years, a slow decline of meals prepared and consumed at home has occurred, with a shift to eating more food away from home (Agriculture and Agri-Food Canada, 2009). Between 1996 and 2001, food purchased from restaurants increased from 26.3% to 30.9% of the total weekly food expenditure per household in the province of Ontario, Canada (Statistics Canada, 2003). As a result of this shift, food service establishments have a greater potential to impact the health and safety of Ontarians. In a study investigating the distribution of foodborne disease cases and outbreaks reported in Ontario during a four-year period by risk setting, foods served from restaurants was found to be most frequently associated with outbreakrelated foodborne illness (Isaacs, LeBer, & Michel, 1998).
Ontario has a population of over 12 million people (Statistics Canada, 2008) and is divided into 36 organizationally distinct health units that provide public health services and programs to the population within its geographic border (Capacity Review Committee, 2005). The Health Protection and Promotion Act (HPPA), R.S.0. 1990, c. HJ, is the legislation governing public health services in Ontario and provides public health inspectors (PHIs) "with broad powers to investigate and take, or order taken, any steps which are necessary to eliminate, or minimize, the effects of hazards to public health (Ontario Ministry of Agriculture, Food & Rural Affairs, 2008)."
The findings reported herein are part of a larger online survey that also investigated the perceptions and self -identified needs of PHIs in Ontario with regard to specialty foods (i.e., foods from different cultures) and resources in different languages (Pham, Jones, Sargeant, Marshall, & Dewey, 2010a). The objective of this article was to identify and describe: 1) the key food safety issues of importance to PHIs, 2) the level of confidence PHIs have in their current food safety knowledge, 3) the format and types of food safety information resources that PHIs want, and 4) the topics PHIs would like to see in an educational workshop.
Materials and Methods
A cross-sectional, online survey of Ontario PHIs was conducted from April to June 2009. The inclusion criteria for study participation required that participants have a Certificate in Public Health Inspection (Canada) and be employed at one of 36 Ontario health units. Participants were informed that participation in the survey was voluntary, responses were confidential, and that completion of the survey served as informed consent. Our study received ethical approved from the research ethics board at the University of Guelph.
The questionnaire design was developed by the researchers using information from the literature (Browne, 2005; Dillman, 2007; Vaillancourt, Martineau, Morrow, Marsh, & Robinson, 1991). The content of the questionnaire was based on data collected by the researchers from four focus groups conducted with PHIs from the central west region of Ontario during June and July, 2008 (Pham, Jones, Sargeant, Marshall, & Dewey, 201Ob). The questionnaire consisted mainly of closed-ended and semi-open-ended questions (i.e., included an "Other, please specify" option in the response choices), which included checklists, ranking questions, twochoice/multiple-choice questions, and Likert scales. The questionnaire went through a series of five draft iterations; revisions were based on reviews by the authors and pretesting with a PHI.
The online survey software tool Survey-Monkey was used for administering the questionnaire and for data collection. Survey recruitment and correspondence was administered through the Canadian Institute for Public Health Inspectors (CIPHI) Ontario branch e-mail LISTSERV; CIPHI Ontario is a provincial branch of CIPHI, the national professional association that represents PHIs in Canada. Potential participants were notified of the survey and its purposes one week prior to the implementation of the survey. On the start date of the survey, an invitation to participate in the survey was sent to all potential participants with a URL link to the questionnaire on the SurveyMonkey Web site. Two follow-up notices were sent two weeks apart. An incentive was offered to promote survey participation: in all correspondences, potential participants were informed that participation in the survey would make them eligible to be entered in a drawing for one of three $250 cash prizes.
Prior to data analyses, the survey data file was imported into Microsoft Excel 2004 for validation and coding. The data file was examined for patterns of missing data and implausible values. The data were then exported into STATA Version 11 for analyses. Descriptive statistics were calculated to summarize the data. Nominal data was described using frequencies and percentages. The representativeness of the study population to the total population of PHIs at Ontario health units was assessed by comparing the distributions of each population across six geographic regions in Ontario. Data on the regional distribution of Ontario PHIs were obtained by determining the number of PHIs at each health unit, and then grouping these data to determine the number of PHIs working within each region. Comparisons between geographic regions were performed using Chi squared analyses. Differences were considered statistically significant at a level of p < .05.
A total of 256 individuals completed the online survey. Seventeen individuals did not meet the inclusion criteria and were excluded from analyses and calculation of the response rate. Approximately 875 individuals were registered on the LISTSERy resulting in a survey response rate of 27.3% (239/875). Some questions were not answered by all respondents; hence, some analyses were conducted with smaller sample sizes, as noted in the tables. The demographic characteristics of respondents and available information for the target population (all Ontario PHIs) are listed in Table 1. Overall, the regional distribution of the study population was significantly different from that of the target population (df= 5, χ^sup 2^ = 47.2, p < .0001), with overrepresentation in one region and underrepresentation in three regions.
Key Food Safety Issues
From a list provided in the survey, respondents were asked to rate how important they considered various issues in terms of food safety (Table 2). All respondents rated timetemperature abuse, cross contamination, and inadequate hand washing as either "very important" or "important" issues. The remaining issues listed were rated as "very important" or "important" by the majority of respondents (87%-97%); the only exception was with specialty foods (i.e., foods from different cultures), where 51% of respondents rated the issue as "very Ìmportant"/"important," and 42% of respondents rated it as "neither important nor unimportant" in terms of food safety.
Respondents indicated their level of confidence in their current knowledge of various food safety issues (Table 3). Many respondents were "very confident" in their knowledge of time-temperature abuse (83.9%), cross contamination (87.7%), and proper hand washing (91.1%). With regard to specialty foods, 8.0% of respondents (19/237) reported being "very confident" in their knowledge, while 26% of respondents (62/237) reported being "unconfident" or "very unconfident."
Key Food Pathogens
Respondents were asked to indicate their level of concern about various food pathogens in public health (Table 4). Most respondents reported being "very concerned" or "concerned" with Salmonella (98.3%), Campylobacter (95.4%), and E. coli O157:H7 (99.2%).
Respondents indicated their level of confidence in their current knowledge of food pathogens (Table 5). Most respondents were "very confident" or "confident" in their knowledge of the pathogens listed.
Food Safety Resources
Respondents were asked how likely they would be to access a variety of resources if in need of food safety information (Table 6). Approximately 97.5% of respondents reported being "very likely" or "somewhat likely" to contact another PHI. The second resource most likely to be used was a government Web site. Conversely, the two resources that respondents indicated they were "somewhat unlikely" or "very unlikely" to access were an unofficial Web site (68.5%) and an industry Web site (50.0%).
Respondents were asked to rank (in order of importance) the three resources they would most prefer to access if in need of food safety information. The top three resources reported by respondents were: government Web sites (83.5%), another PHI (66.9%), and in-house resources (44.8%).
Preferred Information Dissemination Methods
Nearly all respondents (99.2%) indicated that a computer with high-speed Internet connectivity was readily accessible to them at their workplace. Respondents were asked to judge to what extent they agreed or disagreed with the statement: "An online resource is a convenient way for me to obtain new food safety information"; 98.3% of respondents "strongly agreed" or "somewhat agreed" with this statement.
From a list of options, respondents were asked to select which option they considered to be the most effective medium for disseminating food safety information to PHIs. A Web site was the first choice among respondents with 43.3% of responses, followed by an email newsletter (27.7%), workshop/seminar (18.9%), web seminar/webcast (7.6%), and teleconference (0.4%).
Respondents also indicated how useful they considered various information resources to be to them in their role as a PHI (Table 7). The majority of respondents (94.5%; 225/238) considered regular education time, seminars, or workshops for PHIs to be "very useful" (141/238) or "useful" (84/238). A large number of respondents reported that an e-mail newsletter (86.1%), an online clearinghouse for food safety information (84.8%) , new food safety videos (83.2%), regular meetings with inspectors from other inspection agencies (82.0%), and a layman's interpretation of the Food Premises Regulation (76.5%) would be "very useful" or "useful."
Food Safety Workshop
Approximately 90% of respondents (215/238) indicated that they would be interested in attending a workshop hosted by food safety researchers from the Centre for Public Health and Zoonoses (CPHAZ) and the University of Guelph. Given a list of topics, respondents were also asked to indicate whether they would be interested in seeing each topic covered at the workshop. Emerging food safety issues was the topic in which the most number of participants reported interest (98.6%), followed by specialty foods (95.8%), emerging foodborne pathogens (95.7%), issues with which other inspection agencies are currently involved (86.9%), recent cases of foodborne outbreaks and illnesses (81.9%), and case-based outbreak scenarios (78.7%).
While the survey response rate was lower than anticipated (27.3%), the survey population is estimated to represent approximately onequarter of all PHIs at Ontario health units. The survey respondents also represented a wide range of geographic locations across the province. A higher proportion of PHIs from the central west region participated in the survey than expected. This may reflect the fact that PHIs from this area participated in the initial focus groups as well as the proximity of the University of Guelph to these health units.
Key Food Safety Issues and Pathogens
With regard to food safety issues of concern to public health, time -temp era tur e abuse, cross contamination, and inadequate hand washing were reported to be either "important" or "very important" issues by all respondents. All three improper food-handling practices are among the "Fatal Five," or five major causes of foodborne illness outbreaks in food service establishments (University of Rhode Island Cooperative Extension Food Safety Education, 2000). The majority of respondents reported being "very concerned" or "concerned" about Salmonella, Campylobacter , and E. coli O157:H7 in terms of their risk to public health. These bacteria have been found to be the three leading causes of enteric illness reported in Ontario (Lee & Middleton,2003).
Perceived Knowledge Confidence
The intent of our study was not to assess the level of food safety knowledge of the survey respondents, but to explore how confident they were in their current food safety knowledge and to identify any self -perceived knowledge gaps. The majority of respondents reported confidence in their knowledge about the food safety issues and foodborne pathogens listed in the survey. This confidence might be attributed to food safety comprising a large component of the work of many PHIs. Additionally, it is a significant part of the curriculum in the postsecondary education required to become a PHI in Canada and an area for which many resources are currently available. The only topic area where notably fewer respondents reported being confident in their knowledge was in specialty foods. As specialty foods have only recently become more commonplace, it is a subject area in which many inspectors may not have received training during their education and where adequate food safety information may not yet be available. Ongoing educational training on specialty foods may help PHIs gain knowledge confidence in this area.
Food Safety Resources
While participants were asked what they considered to be the key food safety issues and foodborne pathogens in public health, the survey did not ask whether participants were satisfied with the resources currently available for these topics. It is possible that participants may have reported a need for new or additional resources on these key issues and pathogens had they been asked. For the most part, however, participants reported confidence in their current level of food safety knowledge.
Although a number of food safety information resources are currently available to PHIs, over three-quarters of respondents reported that they were "very likely" to seek information from fellow PHIs and government Web sites when in need of food safety information. Further, when asked to rank which resources they would most prefer to access for food safety information, government Web sites and PHIs were again most often ranked in respondents' top three choices. With many respondents reporting that they considered fellow PHIs to be resources for food safety information, the importance of ongoing training and education for PHIs was highlighted. Ongoing educational training of PHIs would help ensure that up-to-date and reliable food safety information is shared among PHIs.
Preferred Information Dissemination Methods
Participants' responses indicate that an online resource, such as an e-mail newsletter or online clearinghouse, would be an effective strategy to quickly and efficiently disseminate food safety information to PHIs. A resource such as an online clearinghouse (i.e., a web-based database) would provide PHIs with a central area to access food safety information from a variety of sources. It would allow PHIs to search one resource for food safety information at their convenience, in a quick and efficient manner, and allow them to print information and resources as needed. An e-mail newsletter would also allow PHIs to keep up-to-date by alerting them to emerging issues or to the availability of new information or resources. The PHIs in our study reported being very likely to use such resources.
Respondents indicated their desire for ongoing food safety education and training by rating "regular education time, seminars, or workshops" as the resource most useful to them in their role as PHIs. Ongoing educational sessions for PHIs can be used to roll out new food safety information, provide training, distribute information resources, and also provide an opportunity for inspectors to come together, ask questions, and share experiences and insights. The other two resources in which respondents most considered "very useful" or "useful" to them were an e-mail newsletter and an online clearinghouse. These online resources can also be used to disseminate follow-up food safety information initially provided in the educational sessions.
Food Safety Workshop
While workshops and seminars were ranked third by respondents in terms of effectiveness for disseminating food safety information to PHIs, the majority of respondents still indicated that food safety education workshops and seminars for PHIs were of interest to them. Furthermore, participants' responses indicated that they would like new and emerging food safety topics to be the focus of workshops, with almost 95% of respondents reporting emerging food safety issues, specialty foods, and emerging foodborne pathogens as desired topics. Workshops and seminars could be utilized to roll out new food safety information to PHIs, with subsequent follow-up information disseminated through online resources, such as a Web site or e-mail newsletter.
Participation bias may have been introduced because of the volunteer nature of our study. That is, the self-reported data reflect the perspectives only of PHIs who took or were able to take the opportunity to respond (e.g., PHIs with ready access to a computer with high-speed Internet access). Furthermore, the CIPHI Ontario LISTSERV includes only the e-mail addresses of PHIs who have registered on the e-mail list and is not inclusive of all Ontario PHIs. The proportion of the approximately 900 PHIs in Ontario (Ministry of Health and Long- Term Care, personal communication, June 24, 2009) registered with the LISTSERV is unknown; however, it is thought that the majority of the approximately 875 individuals registered with the LISTSERV are Ontario PHIs (P. Heywood, personal communication, February 17, 2009).
Due to the lack of demographic data available to determine the representativeness of the study population, the extent to which the results may be generalized to other Canadian provinces and regions beyond may be limited.
Our study investigated the perceptions of PHIs in the province of Ontario, Canada. Respondents were generally confident in their current knowledge of key food safety issues and foodborne pathogens but were interested in additional food safety education resources nonetheless. Given that most PHIs are likely to have ready access to a computer with Internet connectivity, efforts should be made to develop online resources, such as an online clearinghouse, to disseminate food safety information to PHIs. Respondents reported the need for ongoing food safety education and training for PHIs and indicated that they would like new and emerging food safety topics and issues to be the focus of an education workshop for PHIs. This understanding of the public health inspectors' perceptions, concerns, and self-identified needs will better enable the development of food safety information resources of direct relevance to this population.
Acknowledgements: The authors thank the public health inspectors from across Ontario for their participation in the survey and Peter Heywood, of the Canadian Institute for Public Health Inspectors Ontario Branch, for his assistance. Funding and in-kind support was provided through the Funding Research Excellence Development (FRED), the Canadian Institutes of Health Research (CIHR) Institute of Population and Public Health/Public Health Agency of Canada Applied Public Health Chair, and the University of Guelph (Ontario Veterinary College).
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Mai T. Pham, MSc
Centre for Public Health and Zoonoses,
University of Guelph
Andria Q. Jones, DVM, PhD
Catherine E. Dewey, MSc, DVM, PhD
Department of Population Medicine,
University of Guelph
Jan M. Sargeant, MSc, DVM, PhD
Centre for Public Health and Zoonoses
and Department of Population Medicine,
Ontario Veterinary College,
University of Guelph
Barbara J. Marshall, CPHI, MES
Centre for Food-borne, Environmental,
and Zoonotic Infectious Diseases,
Public Health Agency of Canada
Corresponding Author: Mai Pham, Research Assistant, Centre for Public Health and Zoonoses, University of Guelph, 103 MacNabb House, Guelph, Ontario, NlG 2Wl Canada. E-mail: email@example.com.