Use of a Self-Assessment Questionnaire for Food Safety Education in the Home Kitchen --- Los Angeles County, California, 2006--2008

Foodborne diseases remain an important cause of morbidity in the United States among all age groups (1,2). A potentially important contributor to this morbidity is improper food handling and preparation practices in kitchens at restaurants and in private homes (1,2). In 1998, the Los Angeles County Department of Public Health (LACDPH) established numeric scores for restaurant inspections and posted grades for these inspections publicly; by the end of 1998 this initiative was credited with helping to reduce by 13.1% (compared with 1997) the number of hospitalizations for foodborne infections from nontyphoidal Salmonella, Campylobacter, and Escherichia coli in the region (3). In the spring of 2006, the LACDPH Environmental Health Program launched the Home Kitchen Self-Inspection Program, a voluntary self-inspection and education program, to promote safer food hygiene practices at home. This report describes the implementation of this program and the results from its web-based self-assessment questionnaire, the Food Safety Quiz, for the initial program period of 2006--2008. Overall, approximately 13,000 adults completed the quiz; 34% received an A rating, 27% a B, 25% a C, and 14% received a numeric score because they scored lower than 70% on the self-assessment. Use of interactive, online learning tools such as the Food Safety Quiz can be used to promote home food safety in the community. Further research is needed to evaluate and improve the program content and to assess its effect on changing food handling and preparation practices in the home kitchen.

The Home Kitchen Self-Inspection Program includes a Food Safety Quiz* that is based on emerging evidence that the use of online, interactive learning tools are conducive to problem-based learning, improve self-efficacy and self-mastery of selected skills, and offer convenience and flexibility to the learner (4). The content of the questions was guided by food safety education principles† from the U.S. Department of Agriculture: clean, separate, cook, and chill. The framework of the quiz was based on adult learning theories (4) and emphasized such food handling practices as the need to clean and sanitize cutting boards after handling poultry, the safe handling of raw eggs, and appropriate methods for the refrigeration of cooked and uncooked foods. The quiz provided valuable instruction to respondents about better ways to maintain home food safety.

The quiz, available only in English, queried respondents regarding food handling and preparation practices at home, assigning a letter grade at completion using a scoring algorithm (i.e., A [90%--100%], B [80%--89%], C [70%--79%], or an actual score if the rating was below 70%) that was adapted from, but not identical to, the algorithm used for restaurant grading. Although quiz questions were based on food hygiene standards used routinely to evaluate food safety in full-service restaurants, the questionnaire limited queries about physical structure (e.g., damaged floor tiles and cracked walls) and excluded questions on the food handler certification requirements; instead, the quiz rating algorithm specifically focused on food hygiene practices that are considered by the LACDPH Environmental Health Program to be the most relevant to home kitchens and focused on cleaning and chilling as two areas of food safety that county residents might often overlook when cooking at home.

The quiz included 57 questions; 45 were formatted as equally weighted yes/no questions, simulating an inspection checklist that could be completed within 10 minutes. The remaining 12 questions inquired about demographic information. To receive the final score/self-inspection rating, all questions had to be completed. Respondents who received an A rating were mailed a placard with this grade as recognition for their good food handling practices. During March--May, the first 3 months after launch, the quiz was marketed to the public using printed materials and public service announcements in the local media, including television and radio, and at public events.

During 2006--2008, a total of 27,129 visits to the website were recorded; 19,205 (71%) respondents reported Los Angeles County postal codes,§ for which 13,274 unique respondents completed the quiz. Most respondents were female (68%), ranged in age from 18 to 59 years (78%), spoke English at home (86%), and reported being the primary cook (81%); 17% of respondents believed that they had ever become ill from eating at home (Table 1).

When queried regarding food handling and preparation practices, approximately 27% reported not storing partially cooked foods that would not be used immediately in the refrigerator before final cooking, 28% said they did not remove all jewelry from hands and/or did not keep fingernails trimmed when cooking, and 26% reported that their kitchen shelves and cabinets were not clean and free from dust (Table 2). Approximately 36% of respondents said that they did not have a properly working thermometer inside the refrigerator. Approximately 9% reported that they had flies inside the home; 6% reported cockroaches; and 5% reported rodents inside their homes.

If home kitchens were graded similarly to restaurants and were required to post letter grades in the kitchen based on results from the quiz, 34% of respondents would have received an A rating, 27% a B, 25% a C; 14% would have received a numeric score because they scored lower than 70%.

Reported by

T Kuo, MD, H Dela Cruz, MS, M Redelings, MPH, LV Smith, DrPH, R Reporter, MD, PA Simon, MD, JE Fielding, MD, SM Teutsch, MD, Los Angeles County Dept of Public Health, Los Angeles, California.

Editorial Note

Home kitchen-related foodborne diseases are vastly underreported (1,2). The findings in this report show that even among interested and motivated persons, food handling and preparation deficiencies occur frequently in the home setting. Only approximately one third of respondents completing the quiz would have received an A rating.

Although the percentages of home kitchens assigned A or B ratings (61%) was considerably lower than for full-service restaurants (98%) during 2006--2008 (LACDPH, unpublished data, 2009), these observations would not be directly comparable to restaurants because the self-assessment and grading of home kitchens were exclusively based on respondent self-reports and were intended to promote learning. Restaurants, by contrast, were physically inspected by trained food safety professionals and were required to have at least one certified food handler on staff.

During 1999--2007, foodborne diseases caused a reported 2,590 hospitalizations and 17 deaths in Los Angeles County; approximately 600 hospitalizations occurred in 2007 (5--7). These numbers are considered underestimates because not all foodborne illnesses leading to hospitalization or death are confirmed by laboratory testing (8). In 2006, the most common locations for reported foodborne outbreaks in Los Angeles County were restaurants (16 [43%]), followed by foods that were brought or catered to a work place (five [14%]) or eaten at home (five [14%]) (6). The initial decline in hospitalizations related to foodborne illnesses after the public posting of restaurant grades in Los Angeles County in 1998 (3) stalled after 2002 (5). This pattern suggests that addressing other sources of infection (e.g., the food supply, hazards in the food processing and distribution chain, the workplace, and in particular, the home kitchen) might be important to further reduce foodborne illness (6,8). The Home Kitchen Self-Inspection Program was developed by the LACDPH to further help address this public health problem.

The findings in this report are subject to at least two limitations. First, although approximately 13,000 respondents completed the quiz, the sample of respondents is unlikely to be representative of all county residents for several reasons. Because the questionnaire was available only in English, non-English speaking ethnic minorities could not have participated. Respondents enrolled in this self-assessment exercise based on their interest in food safety. Only persons with computers and access to the Internet were able to participate in the program. Second, the relationship between these practices and conditions and actual home kitchen conditions remains unknown.

The Home Kitchen Self-Inspection Program is the largest effort to date to use a web-based, self-assessment questionnaire as a population learning tool to provide feedback and education about home kitchen safety. LACDPH is applying the information gleaned from the quiz (e.g., implementation barriers, responses about home kitchen practices, and program data biases) to explore ways to improve the program, including 1) increasing the specificity of the question items so that they are more relevant to the home kitchen environment, 2) further tailoring the quiz to ethnically diverse or harder-to-reach communities, and 3) conducting a program evaluation to validate the program's benefits to consumer learning and food handling practices at home. Innovative tools that educate the public about home kitchen safety can complement established restaurant hygiene rating programs and aid other prevention efforts to further reduce foodborne illnesses.

References

1. Scott E. Food safety and foodborne disease in 21st century homes. Can J Infect Dis 2003;14:277--80.
2. Redmond EC, Griffith CJ. Consumer food handling in the home: a review of food safety studies. J Food Protection 2003;66:130--61.
3. Simon PA, Leslie P, Run G, et al. Impact of restaurant hygiene grade cards on foodborne-disease hospitalizations in Los Angeles County. J Environ Health 2005;67:32--6.
4. Bouhnik D, Marcus T. Interaction in distance-learning courses. J Am Soc Information Sci Tech 2006;57:299--305.
5. California Office of Statewide Health Planning and Development. Hospital dataset. Available at http://www.oshpd.ca.gov/hid/dataflow/hospdata.html. Accessed August 31, 2010.
6. Acute Communicable Disease Control Program. 2006 annual morbidity report. Los Angeles, California: Los Angeles County Department of Public Health; 2006:169--74. Available at http://www.lapublichealth.org/acd/reports/annual/2006%20annual%20web%20posting.pdf. Accessed August 31, 2010.
7. Los Angeles County Department of Public Health. Mortality dataset: 1999--2007. Available at http://publichealth.lacounty.gov/dca/dcareportspubs.htm. Accessed August 31, 2010.
8. Mead PS, Slutsker L, Dietz V, et al. Food-related illness and death in the United States. Emerg Infect Dis 1999;5:607--25.

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