Food Protection Trends - July/August 2021 - 401

illnesses and outbreaks in retail food establishments in the
United States include contaminated equipment, food from
unsafe sources, time and temperature abuse when cooking
and holding, and inadequate personal hygiene and health
(3, 4, 16, 41). Between 2009 and 2019, 76 inspections were
conducted in the food or cosmetics enterprises in the USVI,
and during 40 of these inspections, citations were issued
following noncompliance that would lead to biological
hazards in food (43).
In April 2012, a norovirus outbreak linked to no specific
food from the hotel kitchen made 20 employees and 46
guests sick in a hotel resort on St. Thomas Island, USVI. The
implicated pathogen spread from hotel employees to the
guests within 5 days (23). A study to evaluate the food safety
knowledge of foodservice workers at a university campus in the
Republic of Trinidad and Tobago found that respondents had
inadequate knowledge about time and temperature control of
food and about cleaning and sanitizing food contact surfaces,
and they could not identify a sick food handler (49).
The U.S. Food and Drug Administration (FDA) Food Code
(41) provides recommendations for the safe handling of food in
retail and food service establishments to protect the public from
foodborne illnesses. Compliance with these recommendations is
monitored and enforced through routine inspections at least once
in every 6 months by state and local government agencies (41).
Food-handler training such as the ServSafe provide food safety
knowledge, but the knowledge may not translate to behavioral
change (12, 50). This disconnect could be associated with barriers
such as lack of resources needed to perform food-safety practices,
negligence by management, time constraints, lack of motivation,
or training that is usually undertaken away from the facilities
where knowledge is supposed to be applied (2, 15, 18, 33). The
USVI population is diverse in race and socioeconomic status
and speaks several languages, including English, Spanish, and
Creole, and its diversity is seen within the food handler population
(38, 47). Food safety extension educators have a challenge to
effectively communicate with culturally diverse populations that
speak different languages (30).
To meet unique food safety education needs and bring about
positive change in behavior and practices, USVI food handlers
may benefit from onsite and culturally appropriate food safety
resources (5, 34). The purpose of this study was to identify the
key food safety concerns within the USVI's food service industry
and develop onsite, culturally appropriate training resources on
topics of food safety to address these concerns. The hypothesis
was that culturally appropriate and needs-based intervention
in food safety education for the food service industry would
increase positive behaviors in food safety practices.
MATERIALS AND METHODS
The study was conducted in the USVI, including St. John,
St. Thomas, and St. Croix, from summer 2018 to spring 2020,
following approval by Iowa State University's Institutional
Review Board (IRB ID 18-209). The study was completed
in three phases, starting with a needs assessment, followed
by development and validation of food safety educational
materials, and finishing with assessment of the impact of
developed materials on food-handling practices.
Phase 1: Needs assessment
In the summer of 2018, 35 face-to-face focused interviews
were conducted with seven key informants, 23 restaurant
managers and chefs, three roadside food vendors, and two
cooks in charity kitchens. A 5- to 10-min observation of
activities at all food establishments was conducted after the
face-to-face surveys completed by oral interviews. Survey
questions and observations were based on the FDA's 2013
Food Code (41), a version that would have been followed in
2018. The survey covered key topics, including temperature
control, food preparation, serving and holding practices,
food source, hygiene and sanitation, cross-contamination,
and food defense. The survey tool used was modified
from a validated tool by Sneed et al. (37) to include only
questions relevant to the hypothesis. Qualitative data
including establishment characteristics and prevailing
food-handling practices were written in a notebook and/
or recorded with an audio recorder (the method used was
based on agreement with the interviewee). Transcription
followed by qualitative coding occurred using the FDA 2013
Food Code requirements. Based on the coding, knowledge
and behavioral gaps and potential food safety risks were
identified. The four most frequent coding themes were used
for the phase 2 educational materials.
Phase 2: Development and evaluation of food safety
educational materials
Based on the phase 1 results, training flip charts, posters,
and signs were developed to train food handlers. Materials
were designed to include figures, photographs, and minimal
text. This study used a behavior-based intervention, because
previous studies found that such interventions are effective at
improving food handling practices (36, 51). Materials were
evaluated twice, with the first evaluation completed by 11
participants, including 10 restaurant managers and a food
inspector from the USVI Department of Health, and the
second round completed by 24 restaurant managers. In both
evaluations, the design and content of materials were evaluated
based on the validated tool with nine criteria using a Likert
scale of 1 to 5 (1 = criteria not met and 5 = criteria totally met)
(31). The decision about the use of materials depended on the
total scores obtained (Table 1) (31). Six cultural sensitivity
questions and a comments section were included in the survey.
The average of total scores was calculated using Microsoft
Excel (Table 2). The difference between the averages of total
scores for the two evaluations was tested using a t-test at a 0.05
significance level and JMP software (version 15; Cary, NC).
The percentage of respondents who answered yes or no to
cultural sensitivity questions was calculated.
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