2004 Model Practice Application (Public)

Food Smart Program

Stratford Health Department

The “Food Smart” Program is a food safety intervention targeted to Asian food service establishments in Stratford, as well as the total population of consumers who eat food from these establishments. The outcome(s) of this practice were: 1) improved average inspection scores, which were used as an indicator for improved food-handling practices and 2) an observed improvement in the inspection process.

The program goals are: 1) to improve food-handling practices by providing language and culturally appropriate food safety training to workers in Stratford’s Asian food service establishments and 2) to improve communication between food service employees and inspection staff. The program objectives are to contract with a Chinese-speaking food safety trainer to conduct on-site training with each Asian food establishments in town and to train the staff in Chinese words and phrases that will improve their ability to communicate with food service employees during inspections.

The practice addresses the need for safe food-handling practices in an environment where information is primarily exchanged in English while many food workers are not proficient in English. In the past decade or so, a major focus of a food protection program has been to provide training and education to food workers. Although inspection staff tries to include some training as a part of every inspection, language and cultural barriers have long presented enormous barriers to even the most basic communication. Due to this communication barrier and other factors, Asian food establishments have had a fairly problematic inspection history. The practice addresses the need for language and culturally appropriate food safety education.

Asian food establishments in the community were chosen for two reasons:

• To address a very specific need with a specific intervention.
  
  
• To use this approach as a model for addressing other language and cultural diversity issues in the food service industry.

There is also a need to train Spanish-speaking food service workers and foodservice workers who do not read and write well.

Although there has been much discussion about the challenges that non-English speaking food service staff present to food protection programs, and despite the fact that training materials are becoming more available in different languages, the approach of actually teaching the inspection staff a series of words and phrases in Chinese and providing dedicated on-site training to Asian establishments is new. Moreover, the Chinese food safety educator enlightened the inspectors on some of the cultural influences at play in Asian establishments, enabling the inspectors to be more culturally competent and understanding in their communications in the field. Cultural competence training is rarely extended to sanitarians at the local level, so this was another innovative aspect of the project.

The Stratford Health Department plays an important role in this program. This agency applied for and received the funding for this program worked with the Restaurant Advisory Committee to plan the intervention, coordinated with the Chinese food safety trainer, received Chinese language training, and conducted food service inspections. The local health department is also responsible for evaluating the efficacy of the training in terms of worker practices. The Restaurant Advisory Committee, which is comprised of owners and managers from a broad range of local food service establishments, including an Asian establishment, were instrumental in planning this intervention. The entire community of Asian food service establishments accepted the voluntary training intervention. The inspection staff had significant input on the training curriculum and initiated the request for instruction in Chinese to improve their ability to communicate during the inspection process. The Health Department meets several times annually with its Restaurant Advisory Committee. The committee advises the local public health agency on the initiatives they feel would be most beneficial. In addition, the inspection staff spreads the word when they are in the field so that food service managers are aware of new projects, code changes, etc. Mailings are sent to all licensed food service establishments at least quarterly, to provide information and invite comment. This effort to communicate provides the local public health agency with feedback that helps to direct the goals.

The cost to conduct the individual training sessions for the pilot program was approximately $4 thousand, which includes the cost of the Chinese-speaking food safety instructor, travel expenses for the instructor, and the Program Coordinator’s time. The cost for conducting the program a second time, with the addition of the Chinese language training for the inspection staff was approximately $5 thousand.

The program was funded initially by the U.S. Food and Drug Administration, and subsequently by NACCHO through a CDC food safety initiative. Although severe budget cuts challenge the sustainability of the program, the Asian food service establishments have already made a commitment to continue this training annually, even if they must provide funding out of pocket. There has already been discussion of contracting the food safety instructor for an entire day and having one or two of the establishments serve as hosts for all the Chinese-speaking food service employees in the community. The inspector staff training is self-perpetuating in that the staff practices their new language skills during each inspection and continues to learn more phrases from the food service workers during inspections.

The first set of individual training sessions was conducted under an FDA grant from October 1, 2000 to September 30, 2001. The second set of training sessions and the Chinese language training for the inspection staff was conducted under a NACCHO grant which ran from December 2002 to May 2004. Each set of trainings was completed in four days. The training for the inspection staff was a half-day session.

The following steps were taken to put the plan into action:

• Recognize the need for language and culturally appropriate food safety training in Asian food service establishments as well as the need for improved communication between inspection staff and food service employees as Asian food service establishments.
  
  
• Apply and receive funding for proposed intervention.
  
  
• Contract Chinese-speaking food safety specialist to provide individual on-site training sessions and provide Chinese language training to inspection staff.
  
  
• Put together training curriculum based on file reviews of Asian establishments to determine training need.
  
  
• Schedule and conduct training sessions.
  
  
• Compile list of words and phrases most needed by staff for conducting inspections.
  
  
• Schedule Chinese language and cultural competence training for staff.
  
  
• Put words onto small laminated cards and hang on lanyards that the inspection staff wore around their necks.

Process Evaluation: The tasks outlined in the implementation section were identified as the “missing pieces” in the communication with the foodservice workers in the Asian food service establishments. The Asian food service establishment portion of the Food Smart program went surprisingly smoothly. It was anticipated that scheduling would be difficult, but it was not. The timeline was met.

Outcome Evaluation: To evaluate the program’s efficacy, a simple comparison of average inspection scores was used. Re-inspection scores in response to failed inspections were not used, as they tend to be artificially inflated. In addition, the sanitarians completed an observational assessment after training. It can be difficult to use inspection scores to evaluate an intervention because the score does not always capture significant improvements in a facility. For example, if an establishment has eight temperature violations on one inspection, and then only has one temperature violation after the intervention, that improvement, which is significant, will not be reflected in the score, because “food temperature” will still be debited. The Stratford Health Department uses software called Foxpro to maintain inspection data. An average score of all inspections (not re-inspections) was calculated before the intervention and compared to an average score of all inspections (not re-inspections) after the initial intervention. The use of averages rather than individual inspection scores was used to provide a broader sense of the food establishment’s performance over time and with different sanitarians. Although there are currently 11 Asian food service establishments in the community, two of these opened after the intervention began, therefore scores were evaluated from the nine establishments which had several pre and post intervention inspections. The average increase in inspection score after intervention is 5.64 points.

Program staff feel strongly that the increase in average score is a direct result of the intervention. If the changes in inspection score were arbitrary, one would not expect to see such a consistent increase in average score across the board. Staff could not identify any other factor that may have contributed to the change in average inspection score, although the fact that other factors could have contributed cannot be ruled out.

This practice was absolutely worth the resources invested in it. For a relatively modest use of resources, a significant outcome was attained. While only a small number of establishments received this intervention, thousands of consumers will benefit from the improved food handling practices. Having seen the results firsthand, the program is even more firmly committed to working with each language group represented in food service establishments, one at a time. This practice did result in some unexpected consequences. Although it was thought that a program of this nature would provide some enrichment for the staff, it was not realize that the ability to speak some words and phrases in Chinese would have such a powerful impact on their ability to conduct inspections, interact with the food service staff, and actually continue to learn additional words and phrases from food service workers themselves. The importance of clear communication when conducting inspections was understood to a greater extent. Perhaps the most important change identified as a result of the intervention is the improved atmosphere during inspections, which provides endless opportunities for the continuation of training and improvement of food safety practices.

Lessons learned from implementing the program include:

• It is important to have a “people-friendly” food safety instructor who is able to speak the language of the group you are directing the program to, as well as understand underlying cultural issues that may present barriers to training.
  
  
• It is essential to encourage the inspection staff to have input to training curriculum and approaches.
  
  
• The most efficient way to schedule the training is to block out training times and go personally to the establishment to have the management choose the session date and time. The establishments closed down business during the training sessions.

Other local health agencies should not be afraid of taking on a project of this scope and nature. This particular facet of the program was not burdensome. The program provided substantial help to the food establishments and enrichment for the inspection staff. The program was a very positive, fun endeavor that continues to benefit its participants.

The key elements needed to replicate this practice include a food protection program with regular inspection intervals, a consistent enforcement policy, and access to a Chinese-speaking food safety trainer. The inspection staff must have a desire to try innovative approaches to routine tasks.