Numerous studies have reported the critical importance of proper hand washing in food service establishments to prevent foodborne disease outbreaks (Food and Drug Administration [FDA], 2017; Green et al., 2006, 2007; Todd, Greig, Bartleson, & Michaels, 2008). For example, poor personal hygiene was included as one of five risk factors that significantly contributes to foodborne illness in food service and retail food stores (FDA, 2010). Properly washing hands following the correct sequence and required duration is particularly important for reducing the number of microorganisms on hands (Centers for Disease Control and Prevention [CDC], 2018). Unfortunately, observations reveal that proper hand washing compliance is still problematic (e.g., only 24% compliance in full-service restaurants and 48% in delis) (FDA, 2010).
Food handler education is pivotal to improving hand washing but mounting evidence suggests that classical strategies of mere knowledge transfer through lectures and text-loaded materials are not sufficient to drive targeted behavior change (Evans & McCormack, 2008; Schroeder et al., 2016). Pellegrino and coauthors (2015) questioned why hand washing compliance is still minimal after decades of food service employee training and emphasized the role of motivational interventions in changing longterm behaviors. Similarly, Yu and coauthors (2018) argued that knowledge-based training itself could lead to inadequate results and showed the effectiveness of behavior-based training, including active weekly feedback and monetary reinforcement, in improving the hand washing practice of food handlers.
While interest is growing in active and direct types of intervention (i.e., behavioral based training that actively and directly educates managers or employees) (Viator, Blitstein, Brophy, & Fraser, 2015), it often requires intense efforts and operational resources and, consequently, might be impeded by barriers of cost, time, and labor. In other words, it might be costly for managers to monitor each food handler's hand washing practices in order to provide regular feedback and consistently reinforce it in day-to-day operations. Considering an extremely high food service workforce turnover rate that exceeds 70% and the dominance of part-time entry-level employees (National Restaurant Association, 2017), active training and reinforcement becomes more problematic because it must be repeated almost constantly for new employees.
Other methods employ relatively passive and indirect intervention strategies that change the environment or system to increase access to proper hand washing (Pellegrino, Crandall, O'Bryan, & Seo, 2015; Viator et al., 2015). This approach targets more implicit and habitual behavior changes through supportive environments, such as increased accessibility to facilities and knowledge. For instance, the Food and Drug Administration (2010) recommends that "hand wash facilities [are] conveniently located and accessible for employees" and "hand wash facilities [are] supplied with hand cleaner/sanitary towels/hand drying devices" (p. 47). In support of passive and indirect intervention strategies, Green and coauthors (2007) found hand washing occurred significantly more often in restaurants with multiple hand sinks and when the sinks were in employee sight.
Purpose of the Study
The current study addressed whether passive and indirect interventions using a system change could improve food handler hand washing practices. The proper duration of hand washing is essential (CDC, 2018), so we used a water flow timer that can be attached to a faucet and displays the duration of water flow throughout the hand washing process. Further, based on the idea of the facilitating effect of multicomponent intervention strategies (Pellegrino et al., 2015; Viator et al., 2015), an informational poster emphasizing proper hand washing procedures and duration was added to see whether multiple passive and indirect interventions would lead to a synergistic effect. Thus, the presence of a timing device on a faucet and the poster attached above the faucet represented the passive and indirect interventions in this study. Lastly, literature showed that food handlers tend to pay less attention to proper hand washing during periods of high-customer volume (Green et al., 2007; Yu, Neal, Dawson, & Madera, 2018), so we also monitored the impact of customer volume on food handler hand washing practices.
Altogether, the research questions grounding this study were:
* Does the presence of a water flow timer improve food handler hand washing behavior?
* Does the presence of a water flow timer in conjunction with an informational poster improve food handler hand washing behavior?
* Does customer volume affect the impact of the interventions?
Site Selection and Sample
The experiment was conducted in an a la carte restaurant located at a large Midwestern university in the U.S. The restaurant serves as an open-to-the-public class designed to train hospitality management students in a realworld setting. Accordingly, subjects included approximately 70 sophomore and senior students and 9 nonstudent employees who included chefs, service instructors, and managers. The lunch hours were from 11:00 a.m.-1:00 p.m. Tuesday through Friday in order to serve university populations, local customers, and campus visitors. The hand sink used for the intervention was centrally located within the restaurant's kitchen and was the most frequently used of the six hand washing sinks. The sink was located near the dishwashing machine; therefore, it was frequently used by servers after clearing soiled dishes.
Design, Instruments, and Data Collection
A within-group, multiple-intervention experiment was conducted over the course of 4 weeks, from September 12-October 6, and included: 1) baseline phase, 2) single intervention phase using a water flow...