EHJ May 2005, pages 24-25

Could help from the behavioural sciences provide a key to preventing food poisoning? Dr Jeremy Leach takes a close look at one psychological theory

Just imagine if all food proprietors, managers and staff fully complied with food safety laws or even exceeded the requirements. Just imagine if all staff working in food-related businesses followed the advice and information given to them during training courses. Is this just a dream? Maybe not, it could be that a psychological theory formulated in the early sixties, cognitive dissonance, could go some way to producing this environmental health utopia.

Food hygiene statistics are bewilderingly contradictory. We know from Health Protection Agency figures that the number of cases of foodborne illness, although falling, remains unacceptably high. CIEH figures tell us that a large and increasing number of people have attended a formal food hygiene course, at all levels. The Food Standards Agency tells us that the general public's awareness of food safety issues is on the rise.

And yet between January 2000 and March 2001, 45 per cent of all food businesses failed to comply with the law. FSA figures reveal that 39 per cent of food staff admit to not washing their hands after visiting the toilet and 53 per cent not always wash their hands before starting to prepare food. This amounts to a high risk of contamination of food and a greater chance of food poisoning. Yet 98 per cent agreed that food poisoning can be life-threatening and 100 per cent agree that poor food hygiene could ruin the business they work for.

John Ruskin famously wrote: "What we know or what we believe is, in the end of little consequence, the only consequence is what we do." He probably did not have food hygiene in mind when he wrote this but it is an adage that certainly applies to the contradictory evidence surrounding food hygiene statistics.

Caterers seem to recognise the seriousness of food poisoning and the negative effects of poor standards on their business, but they fail to see that their behaviour could jeopardise their business. So, why don't food caterers regularly wash their hands or adhere to temperature control measures?

COGNITIVE DISSONANCE

The answer may lie in the theory of cognitive dissonance first put forward by a psychologist, Leon Festinger, in 1962. The theory goes something like this. Cognitive dissonance is defined as an emotional state set up when two simultaneously held attitudes or thoughts are inconsistent or when there is conflict between belief and overt behaviour (Reber, 1985). In other words, if people do things or behave in a way that directly conflicts with what they believe or know to be right, then that will create an uncomfortable feeling in their minds (cognitive dissonance). This makes people seek ways to reduce the cognitive dissonance so they achieve mental harmony (consonance). Commonly, people do this by excusing their behaviour or by modifying their beliefs to resolve the mental conflict. Examples are drink driving, speeding or extravagant purchases (see examples in box 1). Alternatively, if their beliefs are too strong they may be forced to modify their behaviour to achieve consonance. Returning to our environmental health utopia, by applying this theory catering staff could be forced to comply with food hygiene laws in order to be at ease with themselves.

COGNITIVE DISSONANCE AND FOOD SAFETY

So, how could the FSA and local authorities use cognitive dissonance to improve food hygiene standards? EHPs know the sorts of excuses food handlers employ to reduce cognitive dissonance and achieve consonance: the rule is perceived as irrelevant; it's bureaucracy gone mad; or everything is too hygienic anyway; hygiene is lowering our immunity to illness. These "excuses" give us clues as to how to improve legal compliance, raise standards and prevent foodborne illness.

Education, training and awareness are key. If people do not know that their behaviour and actions could lead to foodborne illness, or that they are breaking the law, then the theory will not work. Without that knowledge in their brain, no cognitive dissonance will be created, because people's actions or behaviour will not, as far as they are aware, contradict with what they know to be right.

Existing and planned food laws should be explained to those working in the food industry. Not simply, that the law states this or that, but reasons why they are important. This makes it easier for people to understand why they have to do something.

Cognitive dissonance also relies on people feeling there is a threat of being caught and of being prosecuted. The current rather laissez faire approach to prosecution may be leading to a lowering of standards. As Robyn Fairman and Charlotte Yapp point out in the Journal of Environmental Health Research (3/2, 44,52, 2004), the chances of being prosecuted must be real. For a business proprietor, just reading in a newspaper about someone else getting caught out is sometimes hard to relate to their business. The reasons for the prosecution must be related to the problems that exist in their own enterprise. One way of getting the message across is through local authority press releases emphasising that poor standards will not be tolerated following a successful prosecution.

National campaigns focusing on activities like hand washing, general cleanliness, temperature control or contamination risks also help, especially when linked to advertising and inspections. Catering workers also need to be presented with clear evidence that food hygiene standards do not weaken people's immunity.

Education and training is also key to preventing cognitive dissonance, but with an increased emphasis that people's own poor practices or lapses could lead directly to someone else at best, becoming ill or at worst dying. If a food handler is told that not washing their hands after handling raw poultry could lead to them being responsible for poisoning someone, it will have more impact than just being told it will lead to food contamination. The one problem to be overcome in relation to this aspect is the time delay between action and outcome, which can range from hours to days, and people will not connect their actions to the results of those actions.

We know customers are unlikely to complain if something is wrong, preferring to just leave a premises and not return. This needs to change. Customers should be educated about expected standards and be encouraged to voice their concerns if things are wrong. The FSA's "eatwell" website lists clues for diners to look out for when assessing hygiene standards.

These clues should also be available in leaflet form and local authorities encouraged to distribute them at a local level, and repeating them on their own websites. If food retailers and catering businesses know customers are noting their hygienic shortcomings and are likely to complain, they are far more likely to take things seriously.

Posters act as stark reminders to staff, to wash their hands and adhere to strict temperature control measures. Messages should be direct and personalised and changed regularly to avoid familiarity.

EHPs need to work more closely with behavioural and social scientists and use their knowledge and theories to assist in bringing about change. After all, nearly all environmental health work is about changing human behaviour and history has taught us that relying on the law alone is not always the most effective way forward

Dr Jeremy Leach is a chartered environmental health practitioner working for Wealden DC in East Sussex. E-mail: Jeremy.leach@wealden.gov.uk. The views expressed in this article are those of the author and not necessarily those of Wealden DC.

FSA websites:

• www.eatwell.gov.uk/healthydiet/eatingouthealthily/hygienestandards/
• www.eatwell.gov.uk/keepingfoodsafe/shoppingforfood/shoppingsafely/