Methods and measures in food service food safety research: A review of the published literature

Purpose

Food handlers working in food service establishments need to perform appropriate and consistent food safety practices to ensure that the prepared food is safe for consumers to eat, as a failure to do so may lead to foodborne illness. It is important to have an in-depth understanding of food handler food safety behaviour in the food service sector to design targeted educational interventions and approaches to safeguard consumers. The purpose of this review is to provide insight to the existing body of research regarding food handler food safety in the food service sector, and to identify future research needs in terms of methods and measures.

Methods

This study is a review of published food safety research studies (n = 118) focusing on food handlers in the food service sector conducted between 2001 and 2021. Data were collated regarding the methods used and the measures assessed in published studies to identify the gaps in current knowledge related to food safety in food service.

Findings

The majority of studies were conducted in the United States (29%), Brazil (17%) and United Kingdom (7%). A large proportion were carried out in restaurants (70%). Less than a third of studies (28%) relied on a mixed method approach for data collection; and only 12% of studies assessed a combination of cognitive and behavioural measures. Observation was used in only 29% of studies. A lack of observational data detailing food safety practices such as handwashing, temperature control, separation and cleaning was determined.

Significance

Such findings indicate a greater need for mixed method approach in future food safety research. It is recommended that the understanding of food handler food safety performance is best obtained through a combined assessment of cognitive and behavioural measures with subsequent triangulation of findings to reduce bias and to obtain reliable results.

Dietetics Student Perceptions of Food Safety Communication to Vulnerable Populations: An International Study

Registered dietitians can play an important role in delivering food safety information to vulnerable population groups. Although dietetic students are reported to perceive food safety to be important for vulnerable population groups, little is known regarding their attitudes toward their role in the delivery of food safety information. Therefore, the purpose of this study was to determine and evaluate the perceptions of dietetic students regarding their role in food safety communication to vulnerable populations from three international institutions. A total of 208 dietetics students participated in the study from Columbus, Ohio, USA (n = 100), Cardiff, Wales, UK (n = 78), and Beirut, Lebanon (n = 30). Predominantly, the students in this study had positive attitudes toward the importance of food safety for vulnerable groups, although more students from Lebanon were skeptical that vulnerable patients were more susceptible to foodborne infections than the general populations (p < 0.001). Data indicated confidence and understanding of food safety principles and a willingness to learn more about food safety for these groups, however, some students in the UK (30%) and USA (31%) were not confident that they could effectively communicate food safety to vulnerable patients. Based on the findings in this and previous studies, adjustments are recommended to the requirements for food safety knowledge among dietetic students to include food safety counseling competency.

Inclusion of Food Safety Information in Home-delivered U.K. Meal-kit Recipes

Home-delivered meal-kit recipe boxes provide consumers with fresh, measured ingredients requiring storage, preparation, and cooking by following a recipe card.Previous literature has suggested that including food safety information within recipes may positively impact behavior. Therefore, there is a need to better understand what food safety information is included on the meal-kit recipe cards. Content analysis was performed on U.K. meal-kit provider recipe cards (n = 359) obtained using citizen science methods. Although 46% of recipes referred to handwashing at the start of recipe preparation, these stated 'wash hands' with no further advice regarding hand hygiene, and half (48%) did not refer to handwashing during recipe preparation. Most recipes included produce (99%) and referred to washing fruit and vegetables (88%). For meal-kits that provided animal proteins (n = 332), 50% referred to storing ingredients in the fridge, and only one recipe referred to recommended temperatures (≤5°C). Where applicable (n = 346), food safety advice to prevent cross-contamination was present in 51% of recipes.Statements concerning cooking adequacy of animal proteins (n = 1306) included subjective cooking guidance, with 35% referring to visual assessment of color and 26% cooking duration. For best practice food safety guidance, two recipes referred to end-point temperature, and one stated to use a temperature probe. While all meal-kit providers provided some food safety-related information in reviewed recipes, information was often not sufficient to inform consumers about food safety risk-reducing behaviors in the domestic setting. Observational research is needed to understand consumer engagement with how food safety information in meal-kit recipes impacts the behavior of consumers.

A case study of food handler hand hygiene compliance in high-care and high-risk food manufacturing environments using covert-observation

Observation of behaviour is superior to cognitive data, which does not equate to behaviour. Covert-observation is seldom used in food manufacturing to assess behaviour. In this case study, closed-circuit-television footage (15 h) in a business were reviewed to assess hand hygiene compliance using an electronic-checklist. Hand hygiene attempts were observed prior to entering high-risk (cake/pie)(n= 47) and high-care (sandwich/salad)(n= 153) production areas. Business hand hygiene protocol required handwashing durations ≥ 20 s. Observed durations ranged 1-71 s, <96% of attempts were <20 s. Significantly longer durations were observed when food handlers were in the presence of others (12 s) than when alone (9 s). Although <99% utilised soap, only 56-69% wetted hands first. Failure to rub all parts of hands was commonplace (<87%) and 24-35% failed to apply sanitiser after drying. Consequently, >98% of observed attempts before entering production areas did not comply with the protocol. Observed non-compliant practices may have implications for food safety in manufacturing.

Assessing Existing Food Safety Resources with United Kingdom-Based Chemotherapy Patients and Family Caregivers for Future Learning Purposes

ABSTRACT

Because the incidence of foodborne infection is more prevalent among cancer patients and the domestic kitchen is a contributor to foodborne infection, appropriate domestic food safety practices are needed to safeguard this at-risk population. Although patients are aware of the increased risk of infection, previous self-reported data indicate potential food safety malpractices among patients and family caregivers, thus suggesting the need for targeted food safety information. However, existing United Kingdom resources provide inconsistent and insufficient food safety information. Involvement of intended end users in the cocreation of interventions increases potential effectiveness. Qualitative data were collated from in-depth interviews and a focus group with United Kingdom chemotherapy patients and family caregivers (n = 35) to determine perceptions and preferences for food safety information by evaluating existing food safety resources from international providers (n = 12). Although participants liked digital interventions (e.g., Web sites and videos), traditional paper-based leaflets were perceived as the most beneficial because they could be referred to on repeated occasions. Despite the drawbacks associated with some resources, combining approaches in a multiresource intervention was favored by patients and family caregivers. Ensuring patients are not overwhelmed with excessive information was important. Short, logical, engaging, educational, and entertaining information to evoke an interest in the topic was preferred. Utilization of graphics to supplement descriptive information may enhance comprehensibility. Interventions need to be appropriate for patients and caregivers, and delivery by trusted health care professionals may enhance the credibility of the message. Preferred approaches to facilitate targeted food safety communication were identified, and these findings can be utilized to cocreate targeted food safety interventions for chemotherapy patients and family caregivers.

HIGHLIGHTS

Awareness and Attitudes of Student Dietitians in Lebanon, UK and USA towards Food Safety

Allied health professionals such as dietitians can play a critical role in providing food safety advice to vulnerable consumers. To maximize food-related health and wellbeing, food needs to be safe and nutritious; consequently, food safety is referred to in international curricula for the training of dietitians. The purpose of this study was to explore the awareness and attitudes of student dietitians from three international institutions towards food safety. A total of 207 student dietitians participated in the study from Columbus, OH, USA (n = 99), Cardiff, Wales, UK (n = 78) and Beirut, Lebanon (n = 30). Completion of the study established that the students in three dietetic training programs lacked awareness of key food safety concepts. Close to half (43%) were not familiar with Campylobacter, with the USA students being significantly less knowledgeable (p < 0.001) with 58% being unaware of the pathogen. Understanding of safe handling of leftovers was the lowest for the students in all institutions; only 46% described appropriate reheating practices, with significantly lower (p < 0.001) understanding in Lebanon (28%). The students reported a good understanding of vulnerable populations and perceived food safety to be important for these groups. However, the knowledge of certain high-risk foods was lacking. For instance, 69% of students thought that fresh squeezed juices and smoothies made with raw fruits and vegetables were safe for vulnerable patients, with the UK students being the least familiar with this risk (16%). This is the first study of its kind to take an international perspective of student dietitian food safety awareness and attitudes; the findings are important to dietetic food safety educators and recommendations are made to further explore the interpretation of food safety requirements in international dietetic curricula. Future studies should extend student dietetic research to address attitudes, self-efficacy and the overall readiness to deliver food safety advice to the patients and the community.

Video observation of hand-hygiene compliance in a manufacturer of ready-to-eat pie and pastry products

Food-handler hand-hygiene can be a contributory factor for food-borne illness. Cognitive data (knowledge/attitudes/self-reported practices), while informative, are not indicative of behaviour, and are subject to biases. Consequently, observation of behaviour is superior to survey data. However, researcher presence in direct observation increases reactivity, whereas video observation gives comprehensive analysis over a longer period, furthermore, familiarity reduces reactivity. Although video observation has been used to assess food safety at retail/foodservice, this valuable method is under-utilized in food-manufacturing environments. For the study, footage (24 h) was reviewed to assess compliance in a food-manufacturing site with company protocol. Video observation of food-handlers entering production (n = 674) was assessed; upon 70 occasions no attempt to implement hand-hygiene was observed. Of attempted hand-hygiene practices (n = 604), only 2% implemented compliant practices. Although 78% of attempts utilized soap, only 42% included sanitizer. Duration ranged from 1 to 69 s (Median 17 s). The study provides hand-hygiene data in an area that observational data is seldom captured.

Domestic Kitchen Microbiological Contamination and Self-Reported Food Hygiene Practices of Older Adult Consumers

Because of increased susceptibility, older adults have an increased risk of foodborne infection, and data suggest elevated incidence; therefore, food hygiene is essential to reduce the risk. Research suggests older adults' inadequate knowledge and negative attitudes toward food hygiene may increase implementation of unsafe food practices. Data on microbiological contamination of domestic kitchens of older adults are lacking. Therefore, this study aimed to determine microbiological contamination of domestic kitchens of older adults. Food contact surfaces and equipment (n = 1,292) in domestic kitchens (n = 100) of older adults (≥60 years) were analyzed to isolate aerobic bacteria, Enterobacteriaceae, Staphylococcus aureus, and Listeria spp.; self-reported hygiene practices were also recorded. Highest contamination levels were determined on in-use cleaning equipment (dish brushes, dishcloths, sponges) with aerobic bacteria <9.3 log CFU per item, Enterobacteriaceae <8.8 log CFU per item, and S. aureus <7.0 log CFU per item. Reported usage length of dish brushes was significantly correlated (P < 0.05) with Enterobacteriaceae contamination. Significant correlations (P < 0.05) were determined between contamination and reported cleaning frequency of refrigerators. Contamination of hand towels in single-occupant households was significantly greater (P < 0.05) than in multioccupant households. The study facilitates novel comparison between reported hygiene practices with microbial contamination, suggesting older adults fail to implement adequate and regular hygiene practices that may increase the possibility of cross-contamination in the domestic kitchen and the associated risk of foodborne illness. Data from this study have determined a need for older adults to improve food hygiene practices in the domestic kitchen.

Food Safety Knowledge and Self-Reported Food-Handling Practices in Cancer Treatment

OBJECTIVES

To explore awareness of foodborne infection risk during chemotherapy treatment, to assess knowledge of risk-reducing food safety practices in patients with cancer and their family caregivers, and to determine self-reported food-handling practices.

SAMPLE & SETTING

A convenience sample of 121 patients receiving chemotherapy and 51 family caregivers of patients receiving chemotherapy in the United Kingdom recruited in the community and using online advertising.

METHODS & VARIABLES

Participants completed a self-report questionnaire to determine food safety knowledge and self-reported food-handling practices.

RESULTS

Although patients receiving chemotherapy and family caregivers reported awareness of food safety practices, self-reported practices indicated that potentially unsafe practices may be used in relation to temperature control, handwashing, safe cooking, and adherence to use-by dates. Such practices may increase the risk of foodborne illness to patients receiving chemotherapy treatment.

IMPLICATIONS FOR NURSING

Nursing research is required to explore the food safety training and awareness of healthcare providers. Highly focused and specifically targeted food safety interventions need to be developed and delivered to increase awareness and to implement food safety practices.

Older Adult Consumers' Attitudes and Perceptions of Risk, Control, and Responsibility for Food Safety in the Domestic Kitchen

Although vast amounts of consumer food safety knowledge and self-reported data exist, attitudinal data detailing perceptions of risk, control, and responsibility are lacking. Such data relating to vulnerable groups, including older adults, are particularly scarce. Perception determination is essential in consumer food safety research to facilitate a comprehensive understanding of the cognitive factors that may impact behavior. Previous research has indicated a relationship between food safety perceptions and behavior. Perceptual data can inform the development of targeted food safety educational interventions. This study was conducted to ascertain older adult consumers' cognitive perceptions regarding food safety. Older adults (≥60 years, n = 100) participated in a computer-assisted personal interview to determine perceived risk, control, and responsibility associated with food safety. Although the potential severity of foodborne illness may be understood, the association between foodborne illness and domestic food preparation may be underestimated. Significant differences were found between perceived personal risk, control, and responsibility and the risks, control, and responsibilities of others ( P > 0.001). Older adults perceived themselves to have lower levels of risk than other individuals have, suggesting perceptions of optimistic bias and personal invulnerability. Perceived greater levels of personal control and responsibility, compared with those of others, suggest perceptions associated with the illusion of control. Correlations were evaluated between personal perceptions of risk, control, and responsibility ( P < 0.05). Low levels of risk were correlated with high levels of control. Those respondents ≥80 years of age perceived higher levels of risk and lower levels of control and responsibility. Cumulatively, older adult consumers expressed perceptions of invulnerability, optimistic bias, and the illusion of control regarding food safety. Such perceptions may undermine attempts to provide education regarding food safety. Food safety messages for this audience must be tailored to overcome such perceptions.

Behavioral Observation and Microbiological Analysis of Older Adult Consumers' Cross-Contamination Practices in a Model Domestic Kitchen

The incidence of foodborne illness is higher in older adults because of their increased susceptibility; therefore, food safety practices are important. However, inadequate knowledge and negative attitudes toward food safety have been reported, which may increase use of unsafe food handling practices. Data on the actual food safety behaviors of older adults are lacking. In this study, food safety practices of older adults were observed and linked to microbiological analysis of kitchen surfaces to identify suspected routes of contamination. Older adults (≥60 years, n = 100) prepared a set meal in a model domestic kitchen sanitized according to a validated protocol to ensure minimal and consistent microbiological loads. Food safety behaviors were observed using ceiling-mounted cameras and recorded using a predetermined behavioral checklist. Surface microbiological contamination also was determined after food preparation. Overall, older adults frequently implemented unsafe food handling practices; 90% failed to implement adequate hand decontamination immediately after handling raw chicken. For older adults who used a larger number of adequate hand decontamination attempts, microbiological contamination levels in the kitchen following the food preparation session were significantly lower ( P < 0.001). The novel utilization of behavioral observation in conjunction with microbiological analysis facilitated identification of potentially unsafe food handling practices as suspected routes of microbiological cross-contamination in a model domestic kitchen. Findings indicate the potential impact on domestic food safety of unsafe food handling practices used by older adult consumers. This innovative approach revealed that a large proportion of older adults implement behaviors resulting in microbiological cross-contamination that may increase the risk of foodborne illness in the home.

An assessment of food safety information provision for UK chemotherapy patients to reduce the risk of foodborne infection

OBJECTIVES

Given the increased risk of foodborne infection to cancer patients receiving chemotherapy treatment, and the risk of listeriosis reportedly five-times greater to this immunocompromised patient group, there is a need to ensure the implementation of domestic food safety practices among chemotherapy patients and their family caregivers. However, information regarding the adequacy of resources to inform and enable patients to implement domestic food safety practices to reduce the risk of foodborne infection is limited. Consequently, this study aimed to evaluate the provision of food safety information available to UK chemotherapy patients.

STUDY DESIGN

In-depth semi-structured interviews and content analysis of online patient information resources.

METHODS

Interviews with patients and family caregivers (n = 15) were conducted to explore food-related experiences during chemotherapy treatment. Online food-related information resources for chemotherapy patients (n = 45) were obtained from 35 of 154 National Health Service chemotherapy providers in England, Scotland, and Wales, the Department of Health (DoH) and three of 184 identified UK cancer charities. Identified food-related information resources were reviewed using a content-analysis approach to assess the inclusion of food safety information for chemotherapy patients.

RESULTS

In-depth interviews established that many patients indicated awareness of immunosuppression during treatment. Although patients reported practicing caution to reduce the risk of communicable diseases by avoiding crowded spaces/public transport, food safety was reported to be of minimal concern during treatment and the risk of foodborne infection was often underestimated. The review of online food-related patient information resources established that many resources failed to highlight the increased risk of foodborne infection and emphasize the importance of food safety for patients during chemotherapy treatment. Considerable information gaps exist, particularly in relation to listeriosis prevention practices. Cumulatively, information was inconsistent, insufficient, and varied between resources.

CONCLUSION

The study has identified the need for an effective, standardized food safety resource specifically targeting chemotherapy patients and family caregivers. Such intervention is essential to assist efforts in reducing the risks associated with foodborne infection among chemotherapy patients.

Time-Temperature Profiling of United Kingdom Consumers' Domestic Refrigerators

Increased consumer demand for convenience and ready-to-eat food, along with changes to consumer food purchase and storage practices, have resulted in an increased reliance on refrigeration to maximize food safety. Previous research suggests that many domestic refrigerators operate at temperatures exceeding recommendations; however, the results of several studies were determined by means of one temperature data point, which, given temperature fluctuation, may not be a true indicator of actual continual operating temperatures. Data detailing actual operating temperatures and the effects of consumer practices on temperatures are limited. This study has collated the time-temperature profiles of domestic refrigerators in consumer kitchens (n = 43) over 6.5 days with concurrent self-reported refrigerator usage. Overall, the findings established a significant difference (P < 0.05) between one-off temperature (the recording of one temperature data point) and mean operating temperature. No refrigerator operated at ≤5.0°C for the entire duration of the study. Mean temperatures exceeding 5.0°C were recorded in the majority (91%) of refrigerators. No significant associations or differences were determined for temperature profiles and demographics, including household size, or refrigerator characteristics (age, type, loading, and location). A positive correlation (P < 0.05) between room temperature and refrigerator temperature was determined. Reported door opening frequency correlated with temperature fluctuation (P < 0.05). Thermometer usage was determined to be infrequent. Cumulatively, research findings have established that the majority of domestic refrigerators in consumer homes operate at potentially unsafe temperatures and that this is influenced by consumer usage. The findings from this study may be utilized to inform the development of shelf-life testing based on realistic domestic storage conditions. Furthermore, the data can inform the development of future educational interventions to increase safe domestic refrigeration practices.

Older Adult Consumer Knowledge, Attitudes, and Self-Reported Storage Practices of Ready-to-Eat Food Products and Risks Associated with Listeriosis

Consumer implementation of recommended food safety practices, specifically relating to time and temperature control of ready-to-eat (RTE) food products associated with listeriosis are crucial. This is particularly the case for at-risk consumers such as older adults, given the increased listeriosis incidence reported internationally among adults aged ≥60 years. However, data detailing older adults' cognitive risk factors associated with listeriosis are lacking. Combining data about knowledge, self-reported practices, and attitudes can achieve a cumulative multilayered in-depth understanding of consumer food safety behavior and cognition. This study aims to ascertain older adults' cognition and behavior in relation to domestic food handling and storage practices that may increase the risks associated with L. monocytogenes. Older adults (≥60 years) (n = 100) participated in an interview and questionnaire to determine knowledge, self-reported practices, and attitudes toward recommended practices. Although the majority (79%) had positive attitudes toward refrigeration, 84% were unaware of recommended temperatures (5°C) and 65% self-reported "never" checking their refrigerator temperature. Although most (72%) knew that "use-by" dates indicate food safety and 62% reported "always" taking note, neutral attitudes were held, with 67% believing it was safe to eat food beyond use-by dates and 57% reporting doing so. Attitudes toward consuming foods within the recommended 2 days of opening were neutral, with 55% aware of recommendations and , 84% reporting that they consume RTE foods beyond recommendations. Although knowledgeable of some key practices, older adults self-reported potentially unsafe practices when storing RTE foods at home, which may increase risks associated with L. monocytogenes. This study has determined that older adults' food safety cognition may affect their behaviors; understanding consumer food safety cognition is essential for developing targeted food safety education.

Analysis of older adults' domestic kitchen storage practices in the United Kingdom: identification of risk factors associated with listeriosis

Increased listeriosis incidence among older adults (≥ 60 years) has been reported internationally, with many cases reported to be sporadic and associated with ready-to-eat (RTE) food products with extended refrigerated shelf life. Given that the home kitchen is recognized as a significant location where foodborne illnesses are acquired, it is important that consumers implement safe food practices to minimize risks. This is crucial for vulnerable consumers, such as older adults. Consumer food safety recommendations in the United Kingdom to reduce the risk of listeriosis at home include (i) following "use-by" dates on unopened prepacked RTE food products, (ii) consuming RTE food products within 2 days of opening, and (iii) ensuring the safe operating temperatures of domestic refrigerators (≤ 5 °C). This study utilized observation, self-reporting, and microbiological analysis to determine actual food storage practices to identify behavioral risk factors. A domestic kitchen survey was conducted in older adult (≥ 60 years) consumers' domestic kitchens (n = 100) in South Wales, United Kingdom. Forty-one percent of foods in home refrigerators were beyond the use-by date, of which 11% were unopened RTE food products commonly associated with listeriosis. Sixty-six percent of opened RTE foods had been or were intended to be stored beyond the recommended 2 days after opening. Older adults failed to ensure safe refrigeration temperatures, with 50% of central storage and 85% of door storage areas operating at temperatures >5 °C. Older refrigerators operated at significantly (P < 0.05) higher temperatures. Given that Listeria monocytogenes was isolated in 2% of kitchens, these findings suggest that storage malpractices may have a greater effect on the potential risk of listeriosis than its presence alone. The study has determined that many older adults fail to adhere to recommendations and subject RTE foods associated with L. monocytogenes to prolonged storage at unsafe temperatures which may render food unsafe for consumption.

Behavioral risk factors associated with listeriosis in the home: a review of consumer food safety studies

Listeria monocytogenes causes human listeriosis, which is associated with the highest hospitalization and mortality rates of all foodborne illnesses. In recent years, the incidence of listeriosis has doubled in Europe, almost exclusively among older adults (≥ 60 years of age). Food safety factors associated with increased risk of listeriosis include lack of adherence to "use by" dates and ineffective refrigerated storage of foods. Consequently, older adult consumers' implementation of safe food practices should be evaluated. This article is a review of consumer food safety cognitive and behavioral data relating to risk factors associated with listeriosis in the home as reported in 165 consumer food safety studies. Overall, only 41% of studies included assessment of consumer cognitive or behavioral data associated with listeriosis; of these studies 59% included data on safe refrigeration, 54% included data on storage time for opened ready-to-eat foods, and 49% included data on adherence to use-by dates. In most (83%) of the studies, survey-based data collection methods (questionnaires/interviews) were used; thus, the majority of findings were based on self-report (74%) and knowledge (44%). Observation (31%) and focus groups (12%) were less commonly used, resulting in a lack of actual behaviors and attitudinal data relating to listeriosis risk factors. Only 7% of studies included food safety data for older adults. Although older adults may fail to implement recommended practices, this review reveals a need for in-depth research to determine food safety attitudes and actual behaviors of older adults in conjunction with knowledge and selfreport of practices linked to increased risks of listeriosis. Such data combined with review findings would inform targeted food safety education to reduce risks associated with listeriosis in the home.

Contamination of bottles used for feeding reconstituted powdered infant formula and implications for public health

AIMS

Microbial contamination of powdered infant formula (PIF) is known to cause gastrointestinal infections in infants. Of concern is intrinsic contamination of the formula with (for example) Salmonella enterica as well as extrinsic contamination from inappropriate handling or ineffective disinfection. The aim of this study was to evaluate organic and microbial contamination of 'in-use' bottles used for feeding infants powdered formula milk in South Wales, UK.

METHODS

To establish baseline contamination levels of 'in-use' bottles, 75 'uncleaned' and 150 'cleaned and ready to re-use' bottles used for feeding infants PIF were analyzed. The microbiological analysis included aerobic colony counts (ACCs), presence/absence and counts of Enterobacteriaceae and Staphylococcus aureus. The level of residual adenosine tri-phosphate (ATP) was determined as an indicator of organic soiling. All bottles were sampled in four sites; inner screwcap, bottle interior; bottle outer rim and teat interior.

RESULTS

Microbial counts up to 10(5)/area were sampled and ATP levels up to 100,051 relative light units (RLUs) were obtained from 'uncleaned' bottles. Findings varied according to bottle site. Enterobacteriaceae and Staphylococcus aureus were isolated from 12-15% of 'unclean' bottles/components (up to 10(2) cfu/area sampled) and contamination was most frequently detected from the screw cap and teat interiors. Data indicated that after use, prior to cleaning, considerable microbial and organic soil remained in the cumulative bottles. Of the ready-to-use bottles reportedly cleaned and disinfected, some had ACCs up to 5.8 x 10(4) cfu/area sampled. Staphylococcus aureus was detected from 4% bottles/components but no Enterobacteriaceae were detected.

CONCLUSIONS

Cumulatively, findings indicate the presence of organic soiling and the potential for survival of bacteria between infant feeds. There is a need for effective education on effective bottle decontamination procedures. This may be achieved by using an audience-centred approach to re-enforce messages to parents and caregivers to implement good hygiene practices, effectively wash and rinse items before disinfection and follow manufacturers' guidelines for disinfection.

The importance of hygiene in the domestic kitchen: Implications for preparation and storage of food and infant formula

Aims: Public concerns relating to food safety remain high with most attention focused on manufactured foods and those served in catering operations. However, previous data have suggested that the home may be the main location for cases of food-borne disease. The aim of this paper is to review the microbiological risks associated with hygiene in the domestic kitchen related to food and infant formula safety.

Methods: Compared to other food sectors, research on consumer food hygiene, domestic food-handling and preparation of infant formula is relatively understudied. Behavioural and microbiological studies of consumer hygiene and the domestic kitchen have been reviewed to incorporate research relating to the safety of infant formula.

Results: Incidence data identify the home as an important location for acquiring food-borne disease. The domestic kitchen can be used for a variety of purposes and is often contaminated with potentially harmful micro-organisms such as Campylobacter and Salmonella. Consumer hygiene habits have frequently been found to be inadequate and relate both to microbial growth, survival and cross-contamination. Due to the reduced immune response of infants, the activities associated with the preparation of infant formula and associated bottles and equipment are of particular concern.

Conclusions: Cumulatively, the data suggest that more effort should be made to educate the consumer in food hygiene, especially when the kitchen is used to reconstitute infant formula. This information needs to be provided in a form appropriate for use by consumers.

Consumer perceptions of food safety risk, control and responsibility

Consumer perceptions of risk, control and responsibility related to microbial food safety in domestic food preparation have been investigated. Results showed that consumers demonstrated judgements of 'optimistic-bias' and the 'illusion of control', as well as notions of perceived invulnerability to food poisoning from self-prepared foods. Statistical associations between perceptions of personal risk, control and responsibility and risk and control attributed to 'other people' have been identified. Findings may have negative implications for the effectiveness of consumer food safety education initiatives. It is suggested that consideration of such judgements and associations during the development of future consumer food safety risk communication strategies may increase their effectiveness.

Consumer food handling in the home: a review of food safety studies

Epidemiological data from Europe, North America, Australia, and New Zealand indicate that a substantial proportion of foodborne disease is attributable to improper food preparation practices in consumers' homes. International concern about consumer food safety has prompted considerable research to evaluate domestic food-handling practices. The majority of consumer food safety studies in the last decade have been conducted in the United Kingdom and Northern Ireland (48%) and in the United States (42%). Surveys (questionnaires and interviews), the most frequent means of data collection, were used in 75% of the reviewed studies. Focus groups and observational studies have also been used. One consumer food safety study examined the relationship between pathogenic microbial contamination from raw chicken and observed food-handling behaviors, and the results of this study indicated extensive Campylobacter cross-contamination during food preparation sessions. Limited information about consumers' attitudes and intentions with regard to safe food-handling behaviors has been obtained, although a substantial amount of information about consumer knowledge and self-reported practices is available. Observation studies suggest that substantial numbers of consumers frequently implement unsafe food-handling practices. Knowledge, attitudes, intentions, and self-reported practices did not correspond to observed behaviors, suggesting that observational studies provide a more realistic indication of the food hygiene actions actually used in domestic food preparation. An improvement in consumer food-handling behavior is likely to reduce the risk and incidence of foodborne disease. The need for the development and implementation of food safety education strategies to improve specific food safety behaviors is reviewed in this paper.