| | Implementation of HACCP and prerequisite programs in school foodservice☆Abstract Objective The objective of this study was to determine food safety procedures and practices related to the hazard analysis critical control point (HACCP) program and prerequisite program implementation in school foodservice. Design This descriptive study used a mailed questionnaire to determine procedures and practices related to HACCP and prerequisite programs implemented in schools. Demographic questions related to school foodservice directors and districts were included. Subjects/settings The questionnaire was mailed to a national random sample of 600 district school foodservice directors, all 536 district school foodservice directors in Iowa, and 33 directors of school districts known to have centralized foodservice systems. Statistical analyses Descriptive statistics were used to summarize data. Principal component factor analysis with varimax rotation identified underlying factors for HACCP procedures and practices items. Cronbach's alpha determined reliability for items within a factor. Multiple linear regression determined relationships among variables, and independent t tests were used to compare centralized and conventional foodservice systems. Results Of 1,169 questionnaires mailed, 414 school foodservice directors responded (35.4% response rate). HACCP programs were implemented in 22% of school districts. Two thirds of the directors had food safety certification. Centralized systems implemented more food safety procedures (21.4±5.6, 20.4±5.1, P=.04) and practices (26.1±3.5, 24.8±4.5, P=.002) than did conventional systems. Having one or more employees with primary responsibility for food safety resulted in a higher number of procedures and practices implemented (P=.031). Applications/conclusions School districts need to implement prerequisite programs so that they are ready for HACCP implementation. There are opportunities for dietitians to provide consulting, training, and technical assistance to schools on HACCP implementation. J Am Diet Assoc. 2003;103:55-60. 0002-8223/03/10301-0004$35.00/0
Food safety has received much emphasis by government agencies and food-related professional associations because of the potential health and economic impact of foodborne illnesses. It is estimated that 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths are attributed to foodborne illnesses in the United States each year ((1)). Recent US General Accounting Office ((2)) testimony indicates that school-related foodborne illness outbreaks increased about 10% per year in the 1990s, which is comparable to the increase in outbreaks in general.
Safe food is one attribute of quality food emphasized by Gilmore, Brown, and Dana ((3)) in their study of school foodservice operations. They stated that ″quality food may be defined as food that is selected, prepared, and served in a way so that it retains its natural flavor and identity, is nutritious and is free of unsafe bacteriological or chemical contaminations” (p 47).
Food safety is important to school foodservice professionals. One recent national study found that nearly 90% of district school foodservice directors believe that checking on food safety was an important part of their job, and 82% indicated that it was important for them to learn more about food safety issues ((4)).
According to the General Accounting Office ((5)), 8 of 20 foodborne outbreaks reported to the Centers for Disease Control and Prevention (CDC) in 1997 were associated with school meal programs. School outbreaks related to salmonella ((6)) and Escherichia coli [7], [8] illustrate the health and financial impact of school-related foodborne illness.
To provide safe food and prevent foodborne illness outbreaks, hazard analysis critical control point (HACCP) programs are recommended. The National Advisory Committee on Microbiological Criteria for Foods ((9)) defined HACCP as ″a management system in which food safety is addressed through the analysis and control of biological, chemical, and physical hazards from raw material production, procurement and handling, to manufacturing, distribution, and consumption of the finished product” (p 1,248).
HACCP programs are important for maintaining food safety in school foodservice, yet it seems that HACCP programs are not implemented widely. Further, prerequisite programs, defined as those procedures that ″address operational conditions providing the foundation for the HACCP system” (9, p 1,247), may not be in place. Prerequisite programs would include such things as supplier control, written specifications, written cleaning and sanitation procedures, and documented employee training. Hwang, Almanza, and Nelson ((10)) reported that the majority (87%) of Indiana school foodservice directors have not implemented HACCP programs. In a national study, Giampaoli, Sneed, Cluskey, and Koenig ((4)) found that 70% of school foodservice directors do not have comprehensive HACCP programs in place.
In addition, many basic food-handling practices are not implemented in school foodservice. Research by Gilmore and colleagues ((3)) showed that air circulation in freezers was not adequate because of tight packing in freezers. Food handlers often did not restrain hair and had poor personal hygiene practices such as inadequate hand washing. Employee food-handling practices in 15 on-site school kitchens were examined recently ((11)), and it was found that most poor food-handling practices related to time and temperature. Only 8 of 15 on-site kitchens routinely used thermometers. The failure to transfer food to cold storage during preparation steps was identified. Hand washing was another problem identified.
Hwang, Almanza, and Nelson ((10)) found that the level of school foodservice managers' sanitation knowledge, certification, sanitation training program availability, sanitation practices, and size (number of breakfasts and lunches served per day) were related positively to operations that implemented HACCP programs. There has been no research related to prerequisite program implementation in school foodservice.
The purpose of this research was to determine food safety procedures and practices used in school foodservice related to HACCP and prerequisite programs. In addition, these factors were compared for centralized and conventional foodservice systems because there are no data available on differences between these two foodservice systems.
Methodology  Sample selection A national random sample of 600 district school foodservice directors, purchased from Market Data Retrieval (Shelton, CT), and all Iowa school foodservice directors (n=536) were included in the study sample. To ensure representation of school districts with centralized foodservice systems, a list of foodservice directors (n=33), acquired through the school foodservice listserv, MealTalk, was included. Questionnaire design A written questionnaire was developed for this study. Part I included 34 questions related to food safety procedures, including implementation of a HACCP plan and prerequisite programs such as standard operating procedures, sanitation and hygiene procedures, and procedures for receiving and storage. Yes/no responses were given for each question. Scores were assigned as a 1 (yes) or 0 (no). Part II of the questionnaire consisted of a list of 18 practices that would indicate the presence of HACCP prerequisite programs. Specific questions related to steps in the flow of food (purchasing, receiving, storage, production, and service) were included. Four questions about delivery methods were asked of directors in centralized foodservice systems. For each practice, respondents indicated the frequency that the practice was followed in their schools using the scale always/daily, sometimes, and never, which were scored 3, 2, and 1, respectively. Items included in parts I and II were developed based on guidelines of the National Advisory Committee on Microbiological Criteria for Foods ((9)) and the ServSafe course book ((12)). Questions were grouped by prerequisite program area to ensure coverage of all areas. All questions are included in Tables 1 and 2. | | |  | Food safety procedures | Centralized, yes | Conventional, yes | |
|---|
| | ← n (%) → | |
|---|
| HACCP (α=0.86)a,b | | | |
| Procedures to periodically take and record the temperatures of all potentially hazardous foods as they flow through the operation | 155 (73) | 129 (67) | |
| A linear product and traffic flow (eg, food is received, placed in storage, prepared, and served with little crossing of paths between steps) that minimizes cross-contamination | 153 (72) | 135 (70) | |
| Temperature logs for all cooling equipment (refrigerators, freezers, and chillers) | 145 (68) | 112 (58) | |
| Written specifications for all ingredients and food products | 139 (65) | 91 (47) | |
| Standardized recipes with critical control points | 134 (63) | 118 (61) | |
| Preventive maintenance schedules | 115 (54) | 96 (50) | |
| Standardized recipes with instructions for handling leftovers | 115 (54) | 91 (47) | |
| Procedures in place to check temperatures of refrigerated and frozen foods at receiving | 110 (52) | 90 (47) | |
| Equipment calibration schedules (ie, checking temperature accuracy of ovens) | 107 (50) | 102 (53) | |
| Written procedures for cleaning and sanitizing all equipment | 98 (46) | 76 (39) | |
| Written procedures for cleaning the facility | 94 (44) | 78 (40) | |
| Temperature logs for heating equipment (eg, cook tank) | 77 (36) | 55 (29) | |
| Assurance or documentation from suppliers that they follow a HACCP program | 59 (28) | 48 (25) | |
| Procedures to save samples of prepared food for analyses if required | 59 (28) | 46 (24) | |
| Procedures for checking the condition of the supplier's delivery trucks (eg, sanitation, temperature) | 59 (28) | 43 (22) | |
| Food product flow charts (listing of steps of food flow from receiving to service) | 74 (35) | 39 (20) | |
| A comprehensive HACCP plan | 52 (24) | 36 (19) | |
| Procedures for sending food product samples to laboratory for bacterial testing | 31 (15) | 17 (9) | |
| A HACCP team | 28 (13) | 17 (9) | |
| Procedures for taking swabs of food production equipment and counters to determine bacterial count | 15 (7) | 11 (6) | |
| Standard operating procedures (α=0.79) | | | |
| Procedures implemented for properly thawing foods (eg, thaw in refrigerator or under cold running water) | 206 (97) | 188 (97) | |
| Procedures in place to check the final internal temperature of cooked foods | 202 (94) | 180 (93) | |
| Standard operating procedures for food storage | 193 (91) | 184 (95) | |
| Standard operating procedures for chemical storage | 193 (91) | 182 (94) | |
| Standard operating procedures for cleaning and sanitation | 193 (91) | 180 (94) | |
| Standard operating procedures for handling leftovers | 193 (91) | 179 (93) | |
| Training (α=0.78) | | | |
| All employees trained on personal hygiene | 203 (95) | 185 (96) | |
| All food-handling employees trained on appropriate food-handling procedures | 199 (93) | 179 (93) | |
| All employees trained on cleaning and sanitation | 201 (94) | 180 (93) | |
| Storage (α=0.58) | | | |
| Thermometers in all freezers | 209 (98) | 189 (98) | |
| Thermometers in refrigerators | 210 (99) | 189 (98) | |
| A pest control program | 200 (94) | 178 (92) | |
| Miscellaneous items | | | |
| Employees who follow cleaning and sanitation procedures | 201 (94) | 178 (92) | |
| Thermometers in dry storage | 148 (70) | 126 (65) | | | | |
| | | | Food safety practices | Always/daily | Sometimes | Never | |
|---|
| | Centralized | Conventional | Centralized | Conventional | Centralized | Conventional | |
|---|
| | ← n (%) → | ← n (%) → | ← n (%) → | |
|---|
| Measuring and recording safe food handling practices (α=0.81)a,b | | | | | | | |
| Take and record end-point temperatures of all cooked foods | 137 (64) | 81 (42) | 51 (24) | 72 (37) | 23 (11) | 31 (16) | |
| Take and record temperature of food on the serving line | 119 (56) | 73 (38) | 69 (32) | 70 (36) | 23 (11) | 42 (22) | |
| Check concentration of sanitizing solutions used for sanitizing work surfaces or items washed in the pot and pan sink | 104 (49) | 83 (43) | 87 (41) | 82 (43) | 18 (9) | 22 (11) | |
| Take and record milk temperature in the milk cooler | 89 (42) | 74 (38) | 89 (42) | 76 (39) | 32 (15) | 33 (17) | |
| Take and record dish machine temperatures | 88 (41) | 77 (40) | 69 (32) | 57 (30) | 46 (22) | 46 (25) | |
| Take and record milk temperature upon receiving | 52 (24) | 40 (21) | 84 (39) | 71 (37) | 76 (36) | 75 (39) | |
| Storing food properly (α=0.47)a | | | | | | | |
| Store prepared foods tightly wrapped in clean and moisture-proof materials | 187 (88) | 170 (88) | 23 (11) | 18 (9) | 3 (1) | 1 (1) | |
| Label all items for storage with the production date or the use-by date to ensure proper stock rotation | 158 (74) | 147 (76) | 47 (22) | 39 (20) | 7 (3) | 5 (3) | |
| Calibrate thermometers on a daily basis | 35 (16) | 25 (13) | 116 (54) | 92 (48) | 59 (28) | 71 (37) | |
| Ensuring food safety (α=0.31)a | | | | | | | |
| Follow appropriate personal hygiene practices | 204 (96) | 184 (94) | 8 (4) | 6 (3) | 0 (0) | 0 (0) | |
| Take swabs of food production equipment and counters to determine bacterial count | 1 (1) | 1 (1) | 16 (7) | 12 (6) | 193 (91) | 178 (92) | |
| Send food product samples to a laboratory for bacterial testing | 2 (1) | 0 (0) | 19 (9) | 7 (4) | 190 (89) | 183 (95) | | | | |
Part III consisted of 17 items for obtaining demographic characteristics of respondents (education level, age, gender, number of years employed in foodservice operations, number of years employed in school foodservice operations, and food safety certification) and the school district (number of students, number of students participating in the meal programs, and number of employees). The first question in this part determined the type of food production system, and respondents circled all that applied to their district: 1. On-site (food cooked and served at same school); 2. Regional or base kitchen (food cooked at one site and served at that site and at least one other site/school); 3. Central bakery; and 4. Central kitchen (food cooked at a central kitchen and transported to other sites for service). The questionnaire and study protocol were reviewed and approved by the Human Subjects Committee of the Institutional Review Board (Iowa State University, Ames). Pilot test The questionnaire was pilot tested by graduate students with foodservice experience, Child Nutrition Program state agency staff, and school foodservice directors. Items were added to ensure adequate coverage of areas and reworded to increase clarity based on recommendations of the pilot test groups. Data collection The questionnaire, a cover letter that explained the purpose of the study and encouraged participation, and a postage-paid return envelope were mailed to the study participants. Three weeks after the initial mailing, a follow-up postcard was sent as a reminder. A second questionnaire was sent to directors who did not respond within 7 weeks of the initial mailing. Data analyses SPSS for Windows software (version 10.0, 1999, SPSS, Inc, Chicago, IL) was used for all data analyses. Respondents could answer more than one category for type of foodservice system. For data analysis purposes, responses were divided into two categories. Directors of 193 districts who checked only conventional (on-site) foodservice system were placed in that category. Directors of 213 school districts who checked either centralized or regional foodservice systems were categorized as centralized foodservice systems. Frequency distributions were computed for all variables. Principal component factor analysis with varimax rotation was done for food safety procedures items and for practices items. Based on a minimum eigenvalue of 1.0 and an examination of a scree plot to determine the point of discontinuity, the number of factors was selected. A Cronbach alpha reliability coefficient was calculated to determine the reliability for the items in each factor ((13)). A total score and factor scores for both food safety procedures and practices were calculated by summing responses to all items. For food safety procedures, the total score could be 0 to 34. The food safety practices total score could have a low of 12 to a high of 36. Independent t tests were conducted to compare the total score and factor scores means for conventional and centralized foodservice systems. Multiple linear regression was done to determine relationships between the total score and factor scores, and school foodservice directors' and district characteristics. A probability of equal or less than .05 was considered significant. Results A total of 1,169 questionnaires were mailed to the national random sample, all Iowa directors of school foodservice, and directors known to have centralized foodservice systems. A total of 414 questionnaires were returned, for a 35.4% response rate. Of 536 questionnaires sent to the Iowa sample, 218 questionnaires were returned, a 40.7% response rate. Of the 633 questionnaires sent to the national sample of school foodservice directors and those with centralized foodservice systems, 196 questionnaires were returned, for a 31% response rate. Demographic information Demographic information related to characteristics of school foodservice directors and districts is presented in Table 3.Over 90% of school foodservice directors were female. Two thirds of the respondents reported that they held food safety certification. Fifty percent of the directors estimated that less than 25% of their employees were certified in food safety, and 54% indicated that more than 75% of their managers were certified. | | | | Characteristics | Centralized | Conventional | |
|---|
| | ← n (%)a → | |
|---|
| Age | | | |
| 30 years or younger | 6 (2.8) | 3 (1.6) | |
| 31-50 years | 100 (46.9) | 102 (52.8) | |
| 51-65 years | 101 (47.4) | 83 (43) | |
| Older than 65 years | 3 (1.4) | 4 (2.1) | |
| Education level | | | |
| High school | 57 (26.8) | 68 (35.2) | |
| Some college | 56 (26.3) | 68 (35.2) | |
| Bachelor's degree | 60 (28.2) | 26 (13.5) | |
| Graduate degree | 37 (17.4) | 27 (14) | |
| Years in school foodservice | | | |
| 5 years or fewer | 36 (16.9) | 35 (18.1) | |
| 6-15 years | 85 (39.9) | 93 (48.2) | |
| 16-25 years | 65 (30.5) | 47 (24.4) | |
| 26 years or more | 24 (11.3) | 16 (8.3) | |
| Number of students | | | |
| Fewer than 500 | 14 (7.6) | 59 (33.0) | |
| 501-1,000 | 43 (21.7) | 37 (20.8) | |
| 1,001-2,000 | 34 (17.2) | 25 (14.1) | |
| 2,001-4,000 | 40 (22.2) | 30 (16.8) | |
| 4,001-8,000 | 26 (13.1) | 13 (7.3) | |
| 8,001-20,000 | 22 (11.1) | 8 (4.5) | |
| More than 20,000 | 18 (9.1) | 6 (3.4) | |
| Number of employees | | | |
| Managers/supervisors | | | |
|  20 or fewer | 189 (91.3) | 180 (97.8) | |
| 21-50 | 9 (4.4) | 3 (1.5) | |
| 51 or more | 9 (4.4) | 1 (0.5) | |
| Employees | | | |
| 20 or fewer | 111 (48.6) | 131 (72) | |
| 21-50 | 49 (23.5) | 30 (16.5) | |
| 51-100 | 31 (14.9) | 17 (9.3) | |
| More than 100 | 27 (13) | 4 (2.0) | | | | |
There were 213 centralized and 193 conventional foodservice systems included in the study. Among school districts with centralized foodservice systems, 125 transported food in bulk, whereas 13 preplated foods. The majority (n=111) transported food hot, and 27 transported food chilled. The majority of school districts employed 20 or fewer managers or supervisors, and 56% had 20 or fewer employees. In response to food safety training and certification information, 30% of the districts had one or more employees whose primary responsibility was implementing and monitoring food safety in the foodservice system. Approximately two thirds provided the opportunity to attend a food safety training program in the past 2 years, and 40% provided a food safety training program annually. Half of these school districts had more than 75% of managers certified in food safety, whereas only 14% indicated that the number of employees certified in food safety was more than 75% of total employees. Food safety procedures related to HACCP and prerequisite programs Food safety procedures were categorized into four factors (HACCP, standard operating procedures, training, and storage) based on factor analysis. Responses to these questions are summarized in Table 1. In the HACCP category, 22% of the directors had implemented a comprehensive HACCP plan and 11% had a HACCP team. All items in the standard operating procedures, training, and storage categories were implemented by more than 90% of school foodservice directors. Multiple linear regression models testing the relationship between the total and four factor scores and school foodservice directors' characteristics were not significant. Models testing the relationship between total score and factor scores and school foodservice districts' characteristics were significant for the total score (F=13.14, P=.001) and for the HACCP factor (F=14.65, P=.001). Both models showed positive relationships between the number of students and the number of food safety procedures. Districts with an employee(s) who had primary responsibility for food safety implemented more food safety procedures than districts that did not. Comparison of food safety procedures for centralized and conventional foodservice systems Comparisons by t test were conducted to determine differences for each factor between centralized and conventional foodservice systems. Results of the t test comparisons showed that the total score and the HACCP factor score were different for conventional and centralized foodservice systems. For the overall score, conventional foodservice systems scored 20.4±5.1 and centralized foodservice systems scored 21.4±5.6 (P=.040). Centralized foodservice systems had a higher mean score (8.5±4.7) for the HACCP factor, compared with 7.4±4.4 for conventional foodservice systems (P=.013). Food safety practices Responses to food safety practice items were grouped into three factors (measuring and recording safe food-handling practices, storing food properly, and ensuring food safety) based on factor analysis (Table 2). In the measuring and recording safe food-handling practices category, taking and recording end-point temperatures of all cooked foods was the only practice that over 50% of school foodservice directors always implemented. Two storage practices, storing prepared foods tightly wrapped in clean and moisture-proof materials and labeling all items for storage with the production date or the use-by date to ensure proper stock rotation, were done by 88% and 76% of all school foodservice directors, respectively. In the ensuring food safety category, the majority (95%) of school foodservice directors reported following appropriate personal hygiene practices. Multiple linear regression models testing the total and factor scores for food safety practices and school foodservice director's characteristics were significant for the total score (F=3.35, P=.010) and the first factor, measuring and recording safe food-handling practices (F=4.74, P=.001). Among school foodservice directors' characteristics, education was the only significant characteristic for the total score (β=0.142, P=.001). The models testing the relationship between the total and factor scores and school districts' characteristics were significant for the total score (F=4.35, P=.001) and all three factors: measuring and recording safe food-handling practices (F=4.68, P=.001), storing food properly (F=2.71, P=.007), and ensuring food safety (F=4.74, P=.001). Districts that had an employee(s) with primary responsibility for food safety had a higher total score and score for all three factors than districts that did not have such an employee. For the third factor, ensuring food safety, there was a positive relationship between number of students and factor score. The number of managers was negatively related to all three factors. Comparison of food safety practices in centralized and conventional foodservice systems Comparisons by t test indicated that the mean scores were different for the total score and the first factor (measuring and recording safe food-handling practices) for the two systems. Centralized foodservice systems scored 26.1±3.5, whereaas conventional foodservice systems scored 24.8±4.5 for the total score (P=.002). Centralized foodservice systems had a higher mean score (16.5±3.4) compared with conventional foodservice systems (15.3±3.9) for measuring and recording safe food-handling practices (P=.001). Discussion There have been no studies examining the extent to which food safety prerequisite programs are implemented in school foodservice; therefore, findings of this study will be helpful in determining where to start with HACCP training and implementation. One prerequisite program is training, and we would expect that a high number of foodservice directors, managers, and employees would have food safety certification. Two thirds of the directors were certified, a number similar to the 71% of foodservice directors who had food safety certification in the study by Giampaoli and colleagues ((4)). The numbers of managers and employees reported to be certified is lower, indicating a need to conduct basic food safety training and certification for all levels of school foodservice employees. In this study, 22% of school foodservice directors reported that they had implemented HACCP programs. This is slightly higher than the 14% of school foodservice directors in Indiana who had HACCP programs in place ((10)) and slightly lower than the 30% reported in a recent national study ((4)). Eleven percent reported to have a HACCP team, and 30% reported to have a person with primary responsibility for HACCP implementation. Thus, education is needed on both why and how to implement HACCP programs. Many food safety procedures are reported to be implemented, yet the programs are not compliant with HACCP requirements for documentation. For example, more than 90% of directors reported to have standard operating procedures for thawing foods, taking temperatures, storing food and chemicals, cleaning and sanitizing, and handling leftovers. More than half of these directors do not have written procedures for any of these processes, which is a requirement for HACCP programs. Many food safety practices, such as calibrating thermometers and taking and recording temperatures, are done only sometimes. Giampaoli and colleagues ((11)) also found that cooking temperatures were not taken and temperature logs were not maintained in a small sample of school foodservice operations. Little research has been done to compare food safety procedures and practices related to HACCP and prerequisite programs in centralized and conventional foodservice systems. Kim and Shanklin ((14)) conducted a study in a school district changing from a conventional to a centralized cook-chill foodservice system. They found inconsistencies in serving temperatures in both systems, although there were more inconsistencies with the use of cook-chill, and recommended that standard operating procedures were needed to ensure consistency. The results of this study indicate that foodservice directors of centralized foodservice systems are implementing more food safety procedures and practices than their counterparts in conventional foodservice systems. It should be noted that the difference, although significant, is a small difference that may be of little practical importance. We would expect to see this difference to be greater because there are more critical control points in centralized systems; however, these procedures and practices are important for both foodservice systems. Applications ■HACCP implementation needs to be emphasized in school foodservice. The current 22% of districts reporting to have HACCP programs is insufficient to ensure food safety for school children. ■The items included in the questionnaire can be used by school foodservice directors as a self assessment of the use of prerequisite programs. Results of this study can serve as a benchmark for directors to compare their operation with a national sample of operations. This self-assessment tool also could be used by a school district's HACCP team to evaluate current practices and establish areas where improvement is needed. ■Larger school districts implemented more food safety practices and procedures than did smaller districts. Directors of small districts need to explore ways that they can implement prerequisite programs and move toward HACCP implementation. ■School districts that had one or more employees with primary responsibility for food safety implemented more food safety procedures and practices than those who did not. School districts are encouraged to consider giving one or more employees specific responsibility for providing leadership for prerequisite programs and HACCP implementation to ensure that implementation occurs. ■Consultant dietitians with expertise in food safety may use results of this study to identify areas in which operational resources are needed. For example, there seems to be a need for written standard operating procedures that include food safety components and a need for resources such as temperature logs. These could be developed and marketed by a dietitian. ■Consultant dietitians may identify areas in which they can develop services that can be marketed to school foodservice related to training and prerequisite and HACCP program development and implementation. Acknowledgements The authors wish to recognize these funding sources and to thank all of the school foodservice directors who were willing to participate in this study. References References[1].
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J CHILD NUTR MGT. 1999;23:61–66. S. Youn is a former student at Iowa State University who now resides in Seoul, South Korea. J. Sneed is an associate professor, Hotel, Restaurant, and Institution Management, Iowa State University, Ames ☆ This research was supported by the Food Safety Consortium and the ISU College of Family and Consumer Sciences. PII: S0002-8223(02)00006-8 doi:10.1053/jada.2003.50002 © 2003 American Dietetic Association. Published by Elsevier Inc. All rights reserved. | |
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