Restaurant Inspection and Training Factors Associated with Foodborne Disease and Food Handler Knowledge

Restaurants are a major contributor to the burden of foodborne disease throughout the world. This dissertation examines the relationships between restaurant-related factors, such as inspections and training, and selected outcomes; including foodborne disease outbreaks and knowledge of restaurant staff. Three distinct, but related, observational studies address literature gaps in the field of food safety and guide local food code regulation. In a nationwide survey, completed by local health departments in the United States, we identified jurisdictional level restaurant-related factors associated with foodborne illness outbreaks. Heavy inspection workload was common and foodborne illness outbreaks were more likely to occur among jurisdictions with heavier workload. We recommend workload limitations and the continued practice of risk classification to identify high-risk restaurants and set inspection frequencies. We propose coupling inspections with risk-based interventions, such as food safety education. To establish restaurant food safety intervention priorities for local health departments, we identified knowledge gaps among certified managers employed in Chicago and surrounding Suburbs and among food handlers in Chennai, Tamil Nadu. Using food safety knowledge assessments, we found low overall knowledge and identified knowledge gaps related to cross-contamination, hand hygiene, and proper food cooking and optimal temperatures. In the Chicago area study, we found higher food safety knowledge among managers trained through ServSafe and with English primary language. In Chennai, we found higher knowledge to be correlated with having an Indian Medical Fitness Certificate, which is a medical examination to determine health qualification for food handling. Our results are the first to suggest this relationship and are particularly relevant as newer regulation requires medical certification of all food handlers. Results from both studies support the adoption of evidence-based methods and materials that are linguistically and culturally appropriate and have been shown to improve food safety knowledge and practices.