Foodborne illness is a significant public health problem in the U.S. (Angelo, Nisler, Hall, Brown, & Gould, 2017; Centers for Disease Control and Prevention [CDC], 2013; Gould et al., 2013; Scallan, Griffin, Angulo, Tauxe, & Hoekstra, 2011), resulting in approximately 48 million illnesses, more than 128,000 hospitalizations, and more than 3,000 deaths annually (Scallan, Hoekstra, et al., 2011). Some of these illnesses eventually are linked with outbreaks in retail food establishments (CDC, 2013; Gould et al., 2013), defined by the Food and Drug Administration as an "operation that stores, prepares, packages, serves, vends food directly to the consumer, or otherwise provides food for human consumption such as a restaurant" (U.S. Department of Health and Human Services, 2013). Annually, more than 800 foodborne illness outbreaks are reported to the Centers for Disease Control and Prevention (CDC) and most of these occur in restaurants (CDC, 2013; Gould et al., 2013). In 2016, public health agencies in all 50 states, the District of Columbia, and U.S. territories reported more than 800 foodborne illness outbreaks to CDC and 60% of single-setting outbreaks occurred in a restaurant (CDC, 2018a).
State and local public health departments typically are responsible for investigating restaurant-related outbreaks to 1) understand how and why the outbreak occurred, 2) implement immediate measures to stop the outbreak, and 3) develop long-term measures to prevent future outbreaks.
Environmental assessments (EAs), typically conducted by environmental health staff in public health departments once an outbreak is suspected or confirmed, are an important component of these investigations (Selman & Guzewich, 2014; CDC, 2018b). An EA is a system-based component of a foodborne illness outbreak investigation that fully describes how the environment contributed to the introduction and/or transmission of agents that cause illness. EAs are not the same as a routine inspection--a routine inspection addresses food safety concerns occurring at the time of the inspection.
EAs are designed to thoroughly describe the past environment that led to the outbreak and to identify contributing factors to the outbreak and its antecedents. EAs typically involve the investigator visiting the outbreak establishment and interviewing the manager about establishment characteristics (including food preparation policies and practices and employee practices) that could have contributed to the outbreak. These assessments also typically involve a review of the processes used in the production of food items suspected to be linked to the outbreak and observations of employee food preparation practices. Information collected through EAs is critical to outbreak prevention--it helps investigators determine the environmental factors that contributed to the outbreak, facilitates root cause analysis, and ultimately generates data that can prevent future outbreaks (Food and Drug Administration, 2018). EAs are not always conducted during outbreak investigations (Brown, Hoover, Selman, Coleman, & Schurz Rogers, 2017; Selman, 2010; Selman & Guzewich, 2014;) and the reasons why have not yet been fully explored.
The purpose of this study was to determine the situations and circumstances that facilitate or inhibit EAs during an outbreak investigation. We examined information provided by state and local environmental health staff who reported their outbreak investigation data to CDC's National Environmental Assessment Reporting System (NEARS) (CDC, 2018c). Understanding facilitators and barriers to EAs can help state and local health departments create a working environment that makes conducting an EA easier.
We used Creswell's phenomenology approach (Creswell, 1998) to describe the meaning of our respondents' firsthand experience with EAs--specifically, why they were or were not able to conduct an EA for a given foodborne illness outbreak investigation. We used a grounded theory approach (Corbin & Strauss, 1990; Patton, 2001) to discover patterns and themes in the qualitative data using inductive reasoning. Grounded theory asserts that when in the exploratory phase of research, researchers should not begin analysis with preconceived notions of what they will find. Instead, researchers should recognize patterns and create themes and a set of codes "from the ground up" (Attride-Stirling, 2001). Our study was exploratory in nature; therefore, we created codes as commonalities in responses emerged.
We used qualitative data reported to NEARS for the years...