Foodborne illness is a major cause of morbidity and mortality. Health Canada and the Public Health Agency of Canada estimate that as many as 13 million Canadians suffer from foodborne illness each year (Health Canada, 2007). Corresponding costs associated with this illness range between 12 and 14 billion (Canadian) dollars (Canadian Partnership for Consumer Food Safety Education, 2007). Strategies to control or reduce foodborne illness in Canada and the U.S. consist of regulatory requirements for the food industry combined with some level of consumer education.
At the municipal level, regulatory activities are aimed largely at retail food premises (restaurants, food stores, etc.). Traditionally, these activities have focused on the routine inspection of premises to monitor and enforce compliance with applicable legislation. Many authorities, however, have begun to question the effectiveness of routine inspections versus other potential strategies such as food handler education and public disclosure of inspection findings.
Hamilton Public Health Services (PHS) began exploring this issue, and particularly the effectiveness of routine inspections, in 2005. In Ontario, food premises are assigned either "high," "medium," or "low" risk status based on Hazard Analysis Critical Control Point (HACCP) criteria, an internationally recognized food safety system that involves the identification and control of points in food production where critical problems can occur. High-risk premises are defined as those that serve perishable foods (which therefore support the growth of foodborne pathogens) that involve multiple preparation steps or cater primarily to groups at risk for serious foodborne illness, including full service restaurants and long-term-care facility kitchens. Medium-risk premises are defined as those that also serve perishable foods but with minimal preparation steps and that cater primarily to a general clientele, including fast-food outlets. Low-risk premises include variety stores. PHS strives to meet the Ontario Mandatory Health Program and Service Guidelines that require high-risk premises to be inspected every four months (three times per year), medium-risk premises every six months (two times per year), and low-risk premises annually. Approximately 3,000 food premises in Hamilton are administered by public health inspectors (PHIs) working in geographic districts, including approximately 489 restaurants that are defined as high-risk premises. Inspectors are also responsible for addressing other environmental health issues related to housing, water quality, and communicable disease control in addition to food safety inspections. The typical food premises caseload is 200 premises per inspector district.
Although food premises are routinely inspected, little scientific evidence exists to support the impact of routine inspections on compliance rates, particularly with respect to the frequency of inspections on compliance rates. The available studies (Bader, Blonder, Henriksen, & Strong, 1978; Corber, Barton, Nair, & Dulberg, 1984; Kaplan, 1978; Mathias, Sizto, Hazlewood, & Cocksedge, 1995) provide mixed results or changes to inspection frequency mixed with other regulatory changes (Mathias, Sizto, Hazlewood, & Cocksedge, 1995). Some, for example, suggest that once-or twice-yearly inspections resulted in declines in sanitation and compliance, and once-a-year inspections were insufficient to maintain sanitary conditions (Bader, Blonder, Henriksen, & Strong, 1978; Kaplan, 1978). Conversely, increased frequency of inspection (up to four times per year) resulted in improved sanitation (Allwood, Lee, & Borden-Glass, 1999) although sample sizes were relatively small, while a larger randomized study in Ottawa-Carleton, Ontario, found that increasing the frequency of inspections did not lead to improved sanitary conditions (Corber, Barton, Nair, & Dulberg, 1984).
In Hamilton, however, PHS observed that as routine inspections reached 85% of the mandated provincial frequency (based on 2005 data), compliance with safe food practices levelled off and did not improve with increasing inspection frequency (Table 1). PHS was uncertain whether this trend represented an absolute plateau in effective inspection frequency or whether some increase above the provincial mandate might push compliance higher.
TABLE 1 Inspection Completion and Compliance Rates, Combined High-and Medium- Risk Categories, Hamilton, Ontario, 2001-2006 2001 2002 2003 2004 2005 2006 % Inspection Completion Rate 71 81 85 93 95 91 % Compliance Rate (1) 43 61 77 77 75 76 (1) Compliance Rate = percentage of routine inspections NOT requiring a reinspection. In order to explore this question further, and before committing budget to other potential food safety program enhancements, PHS and the McMaster Institute of Environment and Health (MIEH) conducted a study to analyze the relationship between food inspection frequency and compliance with the expectation that increased inspection frequency would lead to greater compliance rates. Compliance was measured both as a function of observed critical and noncritical infractions (see below) and the number of inspections required per routine inspection conducted.
Materials and Methods
The analysis relies upon a mixed methodology, a combination of both quantitative and qualitative tools. The utilization of a mixed-methods approach allowed the research team first, to gauge the effectiveness of increased inspections as measured by a series of compliance measures capturing critical and noncritical infractions, and second, to include the professional opinions of the...