food safety practices research paper pdf

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List

A Systematic Review and Meta-Analysis of the Effects of Food Safety and Hygiene Training on Food Handlers

Andrea insfran-rivarola.

1 Departamento de Ingeniería Industrial, Facultad de Ingeniería, Universidad Nacional de Asunción, Paraguay, San Lorenzo 2160, Paraguay; [email protected]

2 Facultad de Ingeniería, Arquitectura y Diseño–Universidad Autónoma de Baja California, Ensenada 22870, Mexico; xm.ude.cbau@adnaloy

Diego Tlapa

Jorge limon-romero, yolanda baez-lopez, marco miranda-ackerman.

3 Facultad de Ciencias Químicas e Ingeniería, Universidad Autónoma de Baja California, Tijuana 22390, Mexico; [email protected] (M.M.-A.); [email protected] (K.A.-S.)

Karina Arredondo-Soto

Sinue ontiveros.

4 Facultad de Ciencias de la Ingeniería, Administrativas y Sociales, Universidad Autónoma de Baja California, Tecate 21460, Mexico; [email protected]

Associated Data

Foodborne diseases are a significant cause of morbidity and mortality worldwide. Studies have shown that the knowledge, attitude, and practices of food handlers are important factors in preventing foodborne illness. The purpose of this research is to assess the effects of training interventions on knowledge, attitude, and practice on food safety and hygiene among food handlers at different stages of the food supply chain. To this end, we conducted a systematic review and meta-analysis with close adherence to the PRISMA guidelines. We searched for training interventions among food handlers in five databases. Randomized control trials (RCT), quasi-RCTs, controlled before–after, and nonrandomized designs, including pre–post studies, were analyzed to allow a more comprehensive assessment. The meta-analysis was conducted using the random-effects model to calculate the effect sizes (Hedges’s g) and 95% confidence interval (CI). Out of 1094 studies, 31 were included. Results showed an effect size of 1.24 (CI = 0.89–1.58) for knowledge, an attitude effect size of 0.28 (CI = 0.07–0.48), and an overall practice effect size of 0.65 (CI = 0.24–1.06). In addition, subgroups of self-reported practices and observed practices presented effect sizes of 0.80 (CI = 0.13–1.48) and 0.45 (CI = 0.15–0.76) respectively.

1. Introduction

Food safety is a global public health threat with frequent incidents of foodborne diseases. Additionally, the COVID-19 outbreak has put more pressure on global public health; particularly, organizations of producers and providers along the food supply chain are facing an ongoing challenge to improve and to extreme food safety and hygiene due to the pandemic. In this context, foodborne diseases are responsible for major economic costs for a country [ 1 , 2 ]. In terms of global estimates, in 2010, 31 foodborne hazards caused 420,000 deaths and 600 million foodborne illnesses derived from disease agents, such as non-typhoidal Salmonella enterica , Salmonella typhi , Taenia solium , hepatitis A, and aflatoxins, to name but a few [ 3 ]. In this regard, the application of the Hazard Analysis and Critical Control Point (HACCP) system can improve food safety; however its strength and success in preventing foodborne illnesses depend on it being applied correctly along with the provision of a sanitary infrastructure and the application of principles of good hygiene practice [ 4 ]. Current evidence suggests that a substantial number of foodborne illnesses occur through poor food handling practices of food workers [ 5 , 6 ]. Pathogens may appear in food, for instance, through unsafe farm practices, contamination during manufacturing, packaging, or distributing, or contamination in stores [ 7 , 8 ]. Additionally, food purchases from unsafe sources, inadequate cooking or reheating, holding food at room temperature, cross-contamination, poor personal hygiene, or improper food handling practices frequently contribute to foodborne illnesses [ 9 ].

To fight the battle against foodborne diseases, governments have resorted to strategies including food regulations and laws to monitor compliance with food safety standards [ 10 , 11 , 12 , 13 ]. Additionally, food companies rely on food safety methodologies, including the food Good Manufacturing Practices (GMP), the Good Agricultural Practices (GAP), the Hazard Analysis and Critical Control Points (HACCP) system, and the ISO 22000 standard to assure the safety of their food products [ 14 , 15 , 16 ]. In such methodologies, training food handlers in food safety is one of the most effective strategies for preventing foodborne diseases [ 17 ].

In an attempt to increase both knowledge and practice on food safety and hygiene, different behavioral theories have been used, including the Health Belief Model, in which an individual will perform a preventive behavior depending on their desire to avoid illness (or if ill, to get well) and the belief that a specific health action will prevent (or ameliorate) illness [ 18 , 19 ]; the KAP model, which assumes that an individual’s behavior or practice is dependent on their knowledge (K) and suggests that the mere provision of information will lead directly to a change in attitude (A) and, consequently, a change in behavior or practice (P) [ 20 ]; and the theory of planned behavior (TPB) which focuses on the individual’s intention to perform a given behavior and has been advocated by many researchers for the prediction of determinants of a food handler’s behavior [ 21 , 22 , 23 , 24 , 25 , 26 , 27 ].

In this regard, there is an implied assumption that such training leads to changes in behavior based on the KAP model [ 28 ]. In other words, training affects knowledge [ 29 ] and increased knowledge of correct food hygiene practices may be an important factor in changing behavior [ 22 ], i.e., the provision of food safety and hygiene training and the effective enactment of safe food handling practices are important for controlling foodborne illnesses [ 30 , 31 ]. Unfortunately, in most cases, food hygiene training does not translate into positive food handling behaviors [ 25 , 30 ].

In this regard, knowledge, attitude, and practice (KAP) surveys have been used widely. They are representative of a specific population to collect information on what is known, believed, and done in relation to a particular topic [ 32 ]. In this sense, several studies use training programs based on KAP as well as TPB with the aim of teaching food handlers how to identify food safety hazards and apply good practices regarding food safety.

Knowledge is accumulated through learning processes (which may involve formal or informal instruction), personal experience, and experiential sharing [ 33 , 34 , 35 ]. Traditionally, it has been assumed that knowledge is automatically translated into behavior [ 36 ], despite studies indicating that this is not necessarily true [ 37 , 38 ]. On the other hand, attitude involves evaluative concepts associated with the way people think, feel, and behave [ 39 ]. In the food industry, food handlers must gain knowledge of food safety and be aware of and implement proper food handling practices [ 40 ]. Practice refers to how people demonstrate their knowledge and attitude through their actions [ 41 ].

Previous studies have analyzed the training interventions and relationship between KAP (knowledge, attitude, and practice) and food safety in environments such as hospitals [ 42 , 43 , 44 ], colleges [ 45 , 46 , 47 ], food establishments [ 48 , 49 , 50 ], restaurants [ 51 , 52 , 53 ], and houses [ 54 , 55 , 56 ], among others. Despite the effort made [ 57 , 58 ], further evidence of the effects of training interventions on the knowledge, attitudes and practices toward food safety and hygiene of food handlers from different processes along the food supply chain is needed. To address this gap, we conducted a systematic review and meta-analysis of studies conducting training interventions among food handlers involved in different processes including on farms, in food processing facilities, and in restaurants (i.e., from farm to fork).

2. Materials and Methods

This study adhered closely to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 59 , 60 ]. Figure 1 presents a flowchart of the stages involved in the selection process, while the resulting PRISMA checklist summarizes all of the requirements covered (see online Supplementary Table S1 ). The review was registered in the PROSPERO International Prospective Register of Systematic Reviews (Identifier CRD42019119006).

The PRISMA flow chart.

2.1. Search Strategy

We conducted a comprehensive search on the following databases: PubMed, Cochrane Controlled Register of Trials (CENTRAL), Ebsco, Scopus, and Web of Science. Also, we searched for grey literature on Google Scholar and ProQuest. In relation to the search strategy, we relied on both the Peer Review of Electronic Search Strategies (PRESS) [ 61 ] and the PICOS (population, intervention, comparator, outcome, and study design) elements. The ultimate search strategy is described in the Supplementary Data S1 . We searched for publications in English published between January 1997 and December 2019. Likewise, we examined the reference lists of the retrieved articles to look for further relevant literature. The last search was run in April 2020.

2.2. Study Selection

Two authors reviewed the titles and abstracts of the work retrieved during the search. Discrepancies were resolved by discussion and consensus with a third author. All of the reviewed works were conducted among food handlers from different steps of the food supply chain, including farms, food processing facilities, and restaurants (i.e., from farm to fork). Interventions were defined as food safety and hygiene training sessions covering aspects such as personal hygiene, hand washing, cleaning and sanitization, cross-contamination, foodborne diseases, and temperature control. Training was given in the form of talks, demonstrations, self-practice, and different sources of communication, including posters, videos, booklets, slideshows, and fact sheets. We searched for randomized controlled trials (RCTs), quasi-RCTs, and controlled before-after (CBA) studies. In addition, we searched for non-randomized designs, including uncontrolled pre-post studies, to allow a more comprehensive and complete assessment of the available evidence in the area, recognizing that RCTs may not be feasible for many large-scale food safety education interventions [ 62 , 63 , 64 , 65 , 66 ].

The reported food safety training sessions were aligned with regulations, protocols, and guidelines, including, but not limited to, the United Nations’ (UN) Codex Alimentarius, the HACCP, the Food and Drug Administration (FDA) Food Code (including the hand-washing guidelines and protocol), the FDA’s Employee Health and Personal Hygiene Handbook, the United States Department of Agriculture (SDA) Food Safety Education campaign, the European Union General Food Law, Regulation (EC) No. 852/2004, the United Kingdom’s Safety Act, the GMPs, and the Good Hygiene Practices (GHPs). In all of the studies, the comparison group included either participants (i.e., food handlers) who did not receive food safety training or those who had not yet received proper food safety training.

As the main outcomes, all included studies evaluated changes in knowledge, attitude or practice among food handlers. Knowledge refers to the degree of understanding of food handlers about the food safety information given during training sessions. In contrast, attitude refers to a predisposition or tendency to respond positively or negatively to training. Finally, practices are the actions of an individual in response to the knowledge and attitude involved in the training sessions. Similarly, food safety practices can be defined as the increased use of evidence in healthcare practice and policy when both knowledge of, and attitude toward, food safety are present.

Changes in levels of knowledge were measured in the studies through survey-questionnaire data gathered in Likert-type scales with sub-dimensions such as food poisoning, cross-contamination, temperature control, and personal hygiene. Changes in self-reported attitudes toward food safety and hygiene were also measured through survey-questionnaire data on Likert-type scales. Finally, changes in practices were measured, such as self-reported practices and observed practices, the former through survey-questionnaire data in a Likert-type scale and the latter through checklists. Both used different sub-dimensions, including personal hygiene, food safety, and hygiene, temperature control, cross-contamination, sanitation, storage, and food display. We discarded any case report/series and/or review studies with data missing (e.g., sample size, mean, standard deviation), as well as studies conducted among people other than food handlers (e.g., consumers and food transporters).

2.3. Data Extraction and Quality Assessment

Two independent reviewers screened each potential article to identify its abstract, title, keywords, and concepts reflecting both the article’s contribution and the research context. Disagreements were overcome by discussion. Then, the relevant full-text studies were retrieved and independently assessed by two reviewers against the review’s inclusion/exclusion criteria. Once more, disagreements were overcome by discussion and consensus with a third author. The data were extracted by one reviewer and checked by a second reviewer. The extracted raw data from each study included authors’ names, year of publication, country of origin, title, study setting, study length, study aim, study design, study population, participant demographics, details on the training interventions and control conditions, recruitment and study completion rates, outcomes, measurement times, and information on the risk of bias. The data were arranged manually and tabulated using standardized forms including data from studies that fulfilled our requests for additional information.

2.4. Data Synthesis and Analysis

We stratified data into comparable subgroups for meta-analysis for each outcome: knowledge, attitude, and practice. Furthermore, we separated practice into two subgroups: self-reported practices and observed practices. As in similar cases [ 57 , 66 ], due to studies using different measurement instruments and scales, we calculated the Hedge’s g standardized mean differences (SMD) to measure the effect size, as proposed by Borenstein et al. [ 67 ]. Due to variation across studies, we conducted a random effect meta-analysis using Hedges’s g with a 95% confidence interval (CI) and the two-sided p -value for each outcome [ 67 , 68 ].

Heterogeneity among the studies in terms of effect measures was assessed using the I² statistic. This index can be interpreted as the percentage of total variability in a set of effect sizes due to true heterogeneity (between-studies variability) [ 69 ]. Higgins et al. 2003 suggested the use of I 2 values of 25%, 50%, and 75% as low, moderate, and high, respectively [ 70 ]. Thus, an I 2 value greater than 50% is indicative of substantial heterogeneity. We also assessed the evidence of risk of publication bias through a funnel plot and statistical tests, including Egger’s test [ 71 ] and the Begg’s test [ 72 ] (with a 95% confidence interval). We ran the meta-analysis in RStudio using the metafor package [ 73 ] and the meta package [ 74 ]. To reduce the risk of bias, two independent reviewers assessed each study. Randomized studies were assessed by using Cochrane’s tool RoB2 [ 75 , 76 ]. Here, the judgment criteria included 3 levels (low risk of bias, some concerns, or high risk of bias) for each of the 5 bias domains. Nonrandomized studies were assessed by using the ROBINS-I tool [ 77 ]; the judgment criteria included 5 levels (low, moderate, serious, critical, and no information) for each of the 7 bias domains [ 78 ]. The risk of bias visualization was done using robvis [ 79 ]. Finally, we summarized the findings reported in each study ( Table 1 ).

Summary of Findings.

Note. SD indicates standard deviation; RCT, Randomized control trials; CS, Cross-sectional studies; TL, training length; FU, follow up; GMP, good manufacturing practices; n , sample; nc , control group sample; ni , intervention group sample; mo., Months; h, Hours; min, Minutes. The last name of the main author and the publication year are shown.

During the initial search, we found 1094 papers. Then, after removing duplicates, our database was reduced to 321 papers. Following data screening and the application of exclusion criteria, we removed 200 more studies. One hundred twenty-one studies underwent full-text review. However, after applying the inclusion criteria, only 31 papers were eligible for inclusion in the literature review (see Figure 1 ). We classified the 31 final papers into three categories based on their main outcomes: changes in knowledge, attitude, and practices toward food safety and hygiene following training interventions. Twenty-six of the 31 studies reported changes in knowledge, 12 discussed changes in attitude, and 16 reported changes in food safety practices. Regarding the publication rate, we found that food safety and hygiene training interventions seem to have increased since 2011. Regarding the country of origin, most of the studies were published in the United States (29%), followed by Malaysia (13%), and Canada, Brazil, and the United Kingdom, with equal proportions (6.5%), see Supplementary Tables S2 and S3 . As for the research settings, the studies were conducted mainly in schools or universities (5/31), food process facilities (4/31), hospitals (4/31), restaurants (3/31), street food establishments or food trucks (3/31), farms/greenhouses (2/31), and multi-settings (2/31), among others.

Regarding the sample size, the studies varied from n = 10 to n = 194. There were 64 different interventions conducted among the 31 studies, with face-to-face/lectures (25/64) being the most frequent type of training intervention, followed by lectures combined with practice demonstrations (14/64), computer-based training (6/64), videos (4/64), videos combined with either a lecture (1/64) or a lecture and a demonstration (2/64), lectures combined with an incentive (1/64) or with demonstrations and incentives (2/64), and booklets (2/64), among others. We found that no studies used any kind of intervention involving social media. Regarding the type of study, eleven studies were pre-post studies, twelve relied on RCT, and eight performed a cross-sectional study with a trained group and a non-trained group. As for the measurement instruments, twelve studies administered surveys, one administered a test, two used checklists, and the rest did not report the used measurement instruments. Regarding gender, 13 papers reported that the majority of participants were female, while males represented the majority in nine studies, and one study had an equal proportion (50% of each). Eight studies did not report gender. The main outcomes, descriptions, statistics, and other relevant information of each study are summarized in Table 1 .

We performed a meta-analysis of the effects of food safety training interventions on the KAP of food handlers. Overall, we found that food safety training interventions had a significant effect on knowledge changes, with an SMD of 1.24 (CI = 0.89 to 1.58; p -value = 0.0001). In relation to attitude, our analysis results indicate that food safety training has a positive effect, giving an SMD of 0.28 (CI = 0.07 to 0.48; p -value = 0.008) for the attitudes of food handlers toward food safety and hygiene. Finally, with respect to practice, the overall effect size was estimated to be SMD = 0.65 (CI = 0.24 to 1.06; p -value = 0.0018). For those interventions with self-reported practices, we found an effect size of SMD = 0.80 (CI = 0.13 to 1.48; p -value = 0.0201). In contrast, for studies reporting observed practices, the effect size was SMD = 0.45 (CI = 0.15 to 0.76; p -value = 0.0035). Figure 2 , Figure 3 , Figure 4 , Figure 5 and Figure 6 show the forest plot for each outcome. Overall, food safety KAP was significantly higher as a result of training interventions. This phenomenon was particularly noticeable in the knowledge component. The forest plot in Figure 2 shows that most of the individual results lay close to 1. Such results strongly suggest that training increases knowledge of food safety and improves food safety attitudes and practices among food handlers.

Forest plot—Knowledge.

Forest plot—Attitude.

Forest plot—Overall practice.

Forest plot—Observed practice.

Forest plot—Self-reported practice.

We graphically assessed the risk of publication bias through funnel plots which, as the supplementary Figures S1–S5 depict, were symmetric. The null hypothesis for the Begg’s and Egger’s tests indicated an absence of bias in the selected studies. For knowledge, the Egger‘s test did not indicate any risk of publication bias, while the Begg’s test did indicate a moderate level of risk (i.e., Begg’s test: p -value = 0.044 and Egger’s test: p -value = 0.054); however, the data seem symmetric in the funnel plot (see Figure S1 ). As for the effects of food safety training on attitude changes, we also found no evidence of publication bias, both in tests and in the plot (Begg’s test: p -value = 0.653 and Egger’s test: p -value = 0.763). Finally, we found no statistical evidence of a risk of publication bias for the practice component (Begg’s test: p -value = 0.472 and Egger’s test: p -value = 0.608) and the graphic shows symmetry as well. In this review, the heterogeneity was considered high for knowledge (I 2 = 95.3%), attitude (I 2 = 77.7%), and for practice (I 2 = 94.9%). Regarding the risk of bias for randomized studies, six studies were evaluated with some concerns of risk of bias, four studies with low risk, and two studies with high risk. For nonrandomized studies, ten were evaluated with moderate risk of bias, nine studies with serious risk, and none as low risk. The visualization data are shown in Supplementary Tables S4 and S5 .

4. Discussion

This systematic review has summarized the effects of training interventions on the knowledge, attitudes, and practices of food handlers towards food safety and hygiene. Change in knowledge was assessed in 26 out of 31 studies; therefore, this was the most frequently reported outcome. This result is consistent with previous studies [ 58 , 107 ], and a significant amount of information is available, so it is probably easier to measure knowledge than attitude or practice. We found evidence that training interventions have a significant effect on increased knowledge toward food safety and hygiene across different type of settings such as fresh produce [ 91 ], food service operators [ 108 ], schools [ 80 ], restaurants [ 82 ], households [ 101 ], and multi-settings [ 97 ]. On the other hand, one study found no difference in knowledge between a control and an intervention group except for a positive attitude, so it can be considered to be optimistically biased [ 90 ]. This phenomenon has been demonstrated in previous research [ 90 , 109 , 110 ].

Attitude was assessed in 12 out of 31 studies, most of them assessing one intervention while some studies evaluated two [ 9 , 95 ] or three interventions [ 87 ]. Considering the summarized effect size, a SMD = 0.28 suggests a moderate effect for the positive attitude of food handlers; this is similar to previous studies [ 57 , 58 , 66 ]. Both studies [ 9 , 95 ] reported similar improvements in attitudes, either with face-to-face training or computer-based (CB) instruction. This is consistent with [ 84 ], who stated that participants learned equally well whether the instructional format was CB or instructor-led training. In addition, in studies where food handlers had attended food hygiene training previously [ 97 , 103 ], food safety attitude remained the same. According to our findings, most studies reporting an increase in knowledge also reported an increase in attitude [ 9 , 97 , 105 , 106 ]. However, an increase in knowledge might not necessarily bring about an improvement in attitude. This was the case for four studies [ 80 , 85 , 86 , 100 ]. The reason for this is unclear, yet some factors that could partially explain this could be length of the training [ 80 ], lack of repetition of the training [ 86 ], or previous hygiene enforcement program within the control group [ 85 ]. Attitude is a measure of the degree to which a person has a favorable or unfavorable evaluation of behavior [ 27 ]. In this regard, providing employees with training that does not promote a positive change with attitude [ 80 ], subjective norms, and perceptions of control may not contribute to improving intention (and ultimately behavior) to perform the behaviors [ 111 ].

Practice and behavior were measured in 16 studies, two of them assessing two outcomes (self-reported and observed practice) and the rest just one. The summarized effect of food safety training on practices showed that the interventions increased food safety practices, both for the 11 studies with self-reported practices and the seven studies with observed practices. Previous studies reported similar improvements, either self-reported or observed practices, but with a slightly smaller effect for the self-reported practices [ 38 , 97 ]; this consistent agreement between self-reported and observed behaviors was reported previously [ 23 ]. However, this is contrary to expected, since self-reported data are usually susceptible to social desirability bias [ 112 ], i.e., the tendency of respondents to give socially desirable responses in such a way as to be viewed favorably by others [ 113 ]. Thus, respondents tend to overestimate their food safety practices as being higher than their actual practices deserve [ 38 , 66 , 114 , 115 ]. On the other hand, observed practices could be affected by the “Hawthorne effect” where the changes in a person’s behavior may be due to the presence of an observer.

In this research, inconsistencies between self-reported and observed practices were detected by [ 106 ], with 95% being the self-reported rate of washing hands and 82.5% for keeping hair covered with a cap; however, the observations showed only 50% and 17.5% of compliance, respectively. For studies assessing practices thorough observations, evaluation was mainly done using a checklist [ 38 , 97 , 98 , 99 , 116 ].

The implementation of food safety and hygiene practices has the final objective of preventing foodborne illnesses. Food safety behaviors are often subdivided into specific behavioral constructs such as personal hygiene, adequate cooking of foods, avoiding cross-contamination, keeping foods at safe temperatures, and avoiding food from unsafe sources [ 117 ]. Behavior outcomes provide a more direct measure of intervention effectiveness compared to knowledge and attitudes [ 66 ]; however, food safety practices were measured in only 16 out of the 31 studies. This is consistent with the proportions reported by Viator et al. [ 107 ]. Moreover, an integrative review conducted by Zanin et al., [ 118 ] stated that 50% of the selected studies reported no translation of knowledge into attitudes/practices. In this review, we found evidence of close to 25% translation into both attitudes and practices. In addition, food safety practices of food handlers are associated with the type of management, i.e., tending to be higher in corporate-managed than owner-operated [ 31 ]. Incorporating practical assessment, such as observations, could help owner-operated organizations, since in some cases observation is more important than self-reported practices in order to represent actual behaviors [ 99 , 119 ].

4.1. Food Safety and Hygiene Training

Overall, all nine food safety training interventions that incorporated theory and practice (T&P) demonstrations were more effective in terms of knowledge gain than those that only incorporated theoretical training. This is consistent with [ 83 ], who found that training that incorporated active participation was more effective than traditional passive instruction. Nevertheless, those studies reporting T&P presented a poor improvement in attitude [ 85 , 86 ]. Finally, the seven and eleven interventions based on T&P and theory, respectively, showed similar practice improvement in 71% and 80% of the studies, respectively.

Although the ultimate goal is to prevent foodborne diseases, no study reported an impact on this goal. As expected, the results were based around the change in KAP as a mean to avoid food safety risk. Thus, theoretical training based on KAP is commonly used to improve handlers’ food safety performance [ 106 ]. However, some authors have reported flaws, mainly in the assumption that the received information is translated into practices and behaviors [ 100 , 103 ].

Food safety and hygiene are critical in all steps in the farm-to-fork chain. In an ideal scenario of the farm-to-fork continuum, a total absence of foodborne pathogens and opportunistic bacteria is obviously desired [ 120 ]. Nevertheless, despite good knowledge, attitude, and self-reported practices, there may be poor performance in hygiene [ 121 ] and food safety practices. Bacteria might exist in nature in a range of different metabolic stages, such as dormant, active, and growing; thus, it is important to detect bacteria and ascertain whether they are potentially active [ 120 ]. Despite the central role that food workers’ hands play in bacterial transfer among food and various surfaces [ 81 ], only one study assessed the number of bacteria growing on cultures obtained from the hands [ 86 ], while another demonstrated cross-contamination with hand hygiene sessions using GloGerm ® powder and UV light [ 91 ]. Both studies showed improved knowledge of food handlers. Similarly, it is well known that an effective way to control food poisoning is to maintain hygienic surroundings [ 103 ]. Thus, additional evaluations and inspections including surface cleanliness and hand cultures seem to be a suitable part of training [ 122 ]. Similarly, frequent practical and hands-on sessions will create a much more vivid experience for workers [ 83 , 89 , 91 ]. Active learning, e.g., a training session that raises awareness of the possibility that E. coli bacteria may accumulate under the fingernails should also demonstrate the correct handwashing procedure and require the learner to practice until he or she can successfully demonstrate effective performance of that procedure [ 85 ].

Also, risk perception acts as a guide for decisions about behavior and can be a barrier to following a particular activity or procedure or not [ 123 ]. In this regard, there are different approaches to food safety training. Some include cases of victims of food poisoning [ 91 ] during food safety training to connect with audiences’ lifestyles, incorporate fear, and enhance the perception of risk [ 58 ]. Moreover, to be effective, training programs should be based on appropriate adult education theory [ 124 ], the possibility of human error [ 125 ], and make sure that the reading comprehension level of the text is suitable for most food handlers [ 9 ]. Training programs that are more closely associated with a worksite are potentially more effective, especially if supported by practical reinforcement of the message [ 85 , 126 ].

The frequency [ 51 ] and length of exposure [ 127 ] for a training program are significative factors in the obtained outcome. For studies reporting the length of intervention, the majority were conducted in one day with a follow-up period between 2 and 8 weeks, with 1 year being the longest follow up period [ 82 ]. Moreover, because knowledge decreases over time [ 5 ], food safety and hygiene training should be provided frequently [ 51 ] to prevent the information from being forgotten and also to increase the level of knowledge [ 86 ]. Some studies suggest refresher retraining after 2 years [ 108 ] and before 5 years from initial certification [ 5 ]. For food establishments, we found that the educational level and professional training have significant effects on knowledge, practice [ 49 , 98 ], and food handlers’ positive attitudes [ 49 , 103 ]. However, the inclusion of adult education concepts, skill-based programs with interconnected sessions [ 85 ], and even the use of YouTube ® videos [ 91 ] can be effective for low literacy audiences. In this regard, farm employees with low educational attainment have also demonstrated significant knowledge gain [ 85 , 91 ].

Commitment and motivation from supervisors and management, as well as proper support and facilities given to staff are critical for the success of food safety and hygiene intervention. Training moves people in the right direction but not far enough [ 88 ]. In this regard, food handlers’ attitudes are significantly related to the management environment [ 31 ], thus supervisory support enforcement plays a significative role [ 85 ] in demonstrating and emphasizing the importance of following proper food safety practices [ 88 ], as well as being role models themselves [ 91 ]. Moreover, because transforming knowledge into behavior is complex, training from top management to all employees is crucial [ 128 ], inasmuch as successful food safety intervention must be based on firm theories [ 99 ]. Furthermore, additional key factors are the supervisors’ years of experience [ 5 ], clear responsibilities of food managers, and written agreement related to practicing sanitization procedures [ 99 ], as well as trained and certified managers helping to reduce critical food safety violations [ 129 ].

In terms of settings, most of the studies were carried out in restaurants and street food establishments, hospitals and schools, greenhouses and farms, and industrial food processing companies. This is in accordance with a previous study which found that the most frequently reported settings were restaurants and street food establishments [ 58 ]. In this context, the restaurant industry has been labeled as one of the most recurrent sources of foodborne illness outbreaks [ 130 ]. Therefore, food safety certification of kitchen managers appears to be a significant factor in outbreak prevention in restaurants [ 131 ]. A combination of inspection results with a mandatory training and certification program may mitigate food safety risks [ 132 ].

Many barriers and factors (environmental, social, cultural, belief systems, and so on) can affect whether food handlers effectively implement food safety practices in their workplaces [ 30 , 31 , 122 , 133 ], including a lack of adequate food safety training, time pressure, competing job tasks, lack of or inconvenient locations of equipment/resources, lack of managerial support, lack of motivation/incentive, lack of reminders, or lack of clarity in food safety messages [ 25 , 90 , 98 , 122 , 134 , 135 , 136 ]. As expected, studies from developing countries have experienced some fundamental barriers, including a lack of infrastructure, poor working conditions, ill-functioning equipment, a lack of water, and insufficient supervision [ 89 , 93 ]. Interestingly some studies from developed countries have experienced some limitations regarding literacy [ 94 ] and a potential language barrier [ 83 ], mainly because food handlers were not native speakers.

Regarding the training interventions among the selected studies, 27% were based on international guidelines (including WHO, HACCP, GMP, and ServSafe ® ), 18% on national guidelines, 18% on previous studies, and the remaining studies did not report this information. The guidelines vary by sector (restaurants, meat industry, dairy industry, etc.), legislation, or requirements of the country or region in which a company is located, market conditions, and certifications. Despite the frequent food-related incidents attaching great importance to the certification system [ 137 ], only 41% of the included studies awarded some national or international certification for food handlers. High costs could discourage companies from implementing certifications. In this sense, local governments should support organizations [ 137 ], mainly those that rarely invest in training or certification. A powerful way to win the interest of politicians and policy makers is to be able to attach a monetary value to food-related illness [ 138 ]. In this regard, the overall annual estimated cost of foodborne illness has remained relatively constant since 2005 at approximately GBP 1.5 billion in England and Wales and 152 billion USD in the USA [ 138 ]. Even though regulations and voluntary certifications are commonly thought of as driving forces to improve the safety and quality of food products [ 137 ], legislation might lead food handlers to undergo training only for certification without being motivated to acquire and use new knowledge [ 97 ]. A study found that the number of food safety violations did not differ as a function of certification [ 129 ]. Thus, certifications and legal requirements may not guarantee food safety [ 139 ].

4.2. Limitations

Our study has several major limitations. Firstly, differences in data (settings and data collection/processing approaches) and the multi-component nature of food safety and hygiene training makes it difficult to generalize the results. Second, most studies used observational pre–post designs. As a result, the absence of matched comparison groups, the potential presence of confounding variables, and the lack of randomization prevented the reported outcome improvements from being causally linked to the interventions. Third, the evaluation of KAP limited our ability to make conclusions about the behavior of the food handler. Fourth, knowledge, attitude, and practice are often subdivided into specific constructs; however, our ability to investigate these concepts in detail was limited by the availability and reporting of primary research, as many studies only reported overall scores or scales. Moreover, the determination of workers’ behavior using the self-reported technique before education was an important limitation in some included studies. Finally, there is a possibility that the “Hawthorne effect” led to the improvements reported in the studies.

5. Conclusions

Foodborne diseases continue to be a global problem, causing substantial morbidity and mortality and significant costs. According to our results, food safety and hygiene training have positive impacts on food handlers’ knowledge, attitude, and practice. Effective and frequent food safety training of food handlers continues to be an initial step in ensuring that food safety concepts are at least introduced. Despite knowledge being delivered by training, it cannot just be translated into desired changes in attitudes and practice. The inclusion of practical demonstration and continuous support might increase positive attitudes towards food safety and hygiene practices among food handlers with the ultimate goal of minimizing the incidence and prevalence of foodborne hazards. Moreover, effective food safety training should be relevant to the situation, promote active learning, increase risk perception, and consider the work environment. Because computer-based (CB) training was not found to differ from face-to-face training in terms of the outcome obtained, CB programs could be used more extensively, since they are an efficient and cost-effective way to educate staff.

In this regard, we identified several barriers to attaining proper food safety and hygiene practices, which should be considered by educators with appropriate adjustments according to the stage of the food supply chain, as well as the market, regional, and cultural characteristics. Similarly, training interventions should be based on international or national guidelines and adapted to different sectors, legislations, and certifications. Furthermore, local governments should support organizations, especially those that rarely invest in training and certification like SMEs, small farms, restaurants, or street food services. Finally, certifications and legal requirements may not guarantee food safety and hygiene, but when properly supported by resources, commitment, leadership, and a receptive management culture, food safety and hygiene practices may improve.

Acknowledgments

This study was supported by Mexico’s National Council of Science and Technology, the Programa para el Desarrollo Profesional Docente, para el Tipo Superior (PRODEP) Program and the Universidad Autónoma de Baja California.

Supplementary Materials

The following are available online at https://www.mdpi.com/2304-8158/9/9/1169/s1 , Table S1: PRISMA checklist, Data S1: Search strategy, Table S2: Geographical distribution of studies selected, Table S3: Distribution per year of studies selected, Figure S1: Funnel plot for knowledge, Figure S2: Funnel plot for attitude, Figure S3: Funnel plot for overall practice, Figure S4: Funnel plot for self-reported practice, Figure S5: Funnel plot for observed practice, Table S4: Risk of bias for randomized studies, and Table S5: Risk of bias for nonrandomized studies.

Author Contributions

Conceptualization, A.I.-R. and D.T.; methodology, D.T. and J.L.-R.; formal analysis, A.I.-R., D.T., J.L.-R., M.M.-A., and K.A.-S.; investigation, A.I.-R., D.T., Y.B.-L., and S.O.; writing—original draft preparation, A.I.-R., D.T., J.L.-R., and M.M.-A.; writing—review and editing, Y.B.-L., K.A.-S., and S.O.; supervision, D.T., Y.B.-L., K.A.-S., and S.O. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

• Research article
• Open access
• Published: 03 May 2021

Food safety knowledge, attitude, and hygiene practices of street-cooked food handlers in North Dayi District, Ghana

• Lawrence Sena Tuglo 1 ,
• Percival Delali Agordoh 2 ,
• David Tekpor 3 ,
• Zhongqin Pan 1 ,
• Gabriel Agbanyo 3 &
• Minjie Chu   ORCID: orcid.org/0000-0002-7533-9119 1  

Environmental Health and Preventive Medicine volume  26 , Article number:  54 ( 2021 ) Cite this article

50k Accesses

38 Citations

Metrics details

Food safety and hygiene are currently a global health apprehension especially in unindustrialized countries as a result of increasing food-borne diseases (FBDs) and accompanying deaths. This study aimed at assessing knowledge, attitude, and hygiene practices (KAP) of food safety among street-cooked food handlers (SCFHs) in North Dayi District, Ghana.

This was a descriptive cross-sectional study conducted on 407 SCFHs in North Dayi District, Ghana. The World Health Organization’s Five Keys to Safer Food for food handlers and a pretested structured questionnaire were adapted for data collection among stationary SCFHs along principal streets. Significant parameters such as educational status, average monthly income, registered SCFHs, and food safety training course were used in bivariate and multivariate logistic regression models to calculate the power of the relationships observed.

The majority 84.3% of SCFHs were female and 56.0% had not attended a food safety training course. This study showed that 67.3%, 58.2%, and 62.9% of SCFHs had good levels of KAP of food safety, respectively. About 87.2% showed a good attitude of separating uncooked and prepared meal before storage. Good knowledge of food safety was 2 times higher among registered SCFHs compared to unregistered [cOR=1.64, p =0.032]. SCFHs with secondary education were 4 times good at hygiene practices of food safety likened to no education [aOR=4.06, p =0.003]. Above GHc1500 average monthly income earners were 5 times good at hygiene practices of food safety compared to below GHc500 [aOR=4.89, p =0.006]. Registered SCFHs were 8 times good at hygiene practice of food safety compared to unregistered [aOR=7.50, p <0.001]. The odd for good hygiene practice of food safety was 6 times found among SCFHs who had training on food safety courses likened to those who had not [aOR=5.97, p <0.001].

Conclusions

Over half of the SCFHs had good levels of KAP of food safety. Registering as SCFH was significantly associated with good knowledge and hygiene practices of food safety. Therefore, our results may present an imperative foundation for design to increase food safety and hygiene practice in the district, region, and beyond.

Introduction

A report by the World Health Organization (WHO) (2015) showed that about two million incurable cases of food poisoning materialize annually in unindustrialized nations. The WHO further estimates that 600 million food-borne diseases (FBDs) each year were related to poor food safety and hygiene practice with 420,000 deaths [ 1 ], the majority attributed to meat-related vulnerabilities [ 2 ]. About, 76 million FBDs caused 325,000 hospitalizations in the USA which led to 5000 deaths [ 3 ]. The source was associated with the consumption of turkey contaminated by Salmonella enterica serovar Heidelberg , responsible for salmonellosis in the USA [ 4 ]. Almost, 1.3 million FBDs resulted in 21,000 hospital stays reported in England which led to 500 deaths. The contamination was due to sprouts by Escherichia coli O104 [ 3 ]. Around 53% of the food-borne problems and 31% of its associated illness were attributed to meat consumption in the Netherlands [ 2 ]. The rate of FBDs in Malaysia was 47.8% out of 100,000 people who patronized street-cooked foods [ 5 ]. In Ghana, about 65,000 persons including 5000 kids below 5 years died yearly due to FBDs [ 6 ].

The risk factors such as inappropriate time interval, unsuitable temperature, weather condition, unhygienic activities, unacceptable handling of foods, foodstuff from insecure origins, impoverished self-cleanliness, improper cleaning of cooking materials, using untreated water, and improper food storages were attributed to the causes of FBDs [ 7 , 8 , 9 ]. Also, neglect of hygienic measures by food handlers has been implicated as enablers for the spread of pathogenic microorganisms [ 10 ] and the cause of infections among consumers [ 11 ].

Studies recount that 12 to 18% of food-borne illnesses are attributable to contaminations [ 12 , 13 ], poor food safety, and inappropriate hygiene practices which were accredited to street-cooked food handlers (SCFHs) [ 14 , 15 ]. These SCFHs are people who are wholly or partly engaged in the food preparation, processing, and production value chain and who have a direct touch on food and cooking utensils [ 9 , 16 ]. Foods prepared by food handlers under unhygienic conditions become a public health concern both in industrialized and low-income countries [ 17 ]. Food safety and hygienic practices of SCFHs are essential to ensure that food is free from any forms of contamination through preparation and processing for consumption and to prevent the spread of FBDs [ 18 , 19 ].

Food safety knowledge (FSK) is the understanding of food learned from skills or schooling, food safety attitude (FSA) refers to sensation or belief about food safety, and food safety practice refers (FSP) to the act or use of food safety [ 20 ]. Food safety knowledge, attitude, and practices (KAP) are important because inadequate knowledge, poor attitude, and poor sanitation practices by SCFHs have a severe danger to food safety applications in food companies [ 21 ]; hence, KAP of food safety contributes significantly to the occurrence of food poisoning and FBDs among consumers [ 22 ].

A study conducted in Brazil among food truck food handlers revealed poor hygiene, poor clean observes, poor environments, and higher contaminated meals [ 23 ]. The problem of FBDs was higher in Southeast Asian and African counties [ 24 ]. Ma et al. [ 25 ] study in China, among street food vendors, revealed poor behaviour practices and knowledge of food safety among the respondents. Tabit and Teffo [ 26 ] in South Africa found over 60% of the respondents keep good knowledge and acceptable hygiene performance of food safety. Lema et al. [ 27 ] in Ethiopia reported that below half of the respondents obtained good food cleanliness applications. The effects of food-related illness expenditures in hospital treatments are about US$ 110 billion annually in developing countries, which resulted in decreasing production [ 28 ].

The recurrent happenings of food-related illnesses brought in its wake concerns about the food safety knowledge and hygiene among SCFHs [ 29 ]. Maintaining food safety involves establishing global laws conferring to an agreement between institutions that actualized this agenda [ 30 , 31 ]. The Government of Ghana affirmed food safety regulations in collaboration with the Food and Drug Authority (FDA) [ 30 ]. Yet, its application is undermined due to ineffective supervision by appropriate agencies [ 32 ]. The problem was due to the broad governmental assembly in cities and communities under the local administration [ 31 ]. Some local studies conducted in the four regions of Ghana such as Greater Accra, Northern, Western, and Central have reported adequate knowledge, good attitude, and positive behavioural practices of food safety and handling practices [ 11 , 33 , 34 , 35 ]. Studies have shown that SCFHs were not knowledgeable about the WHO’s Five Keys to Safer Food for food handlers [ 33 , 36 ] which include keeping clean, separating raw and cooked food, cooking thoroughly, keeping food at safe temperatures, and using safe water and raw materials [ 37 ].

Hence, the acceptance and the use of the KAP instrument as a problem-solving approach in this study are validated from previous researches [ 23 , 38 , 39 ]. This would adequately support the policymaking development and the change of embattled intervention policies for the prevention and control of FBDs. The KAP’s tool assessment defined in this study is considered appropriate to other frameworks if the statements in the KAP’s sections are validated. To our knowledge, no research has yet been done on KAP of food safety among SCFHs selling commonly consumable foods on the street in Volta Region, Ghana. Hitherto, the high cases of FBDs such as diarrhoea, cholera, and typhoid fever outbreak occurrences in the district are presumed to be influenced by SCFHs. The KAP of SCFHs on food safety and hygiene precautions ruins uncertainty in the district, and a swift policy to mend some causes central to the occurrence of FBDs is obligatory. This would help the District Health Directorate’s regulatory agency to plan the prevention methods. Therefore, this study assessed knowledge, attitude, and hygiene practices of food safety on SCFHs in North Dayi District, Ghana.

Materials and methods

Study design and setting.

This study was a descriptive cross-sectional carried out between August and November 2020 and used a validated, pretested, and structured questionnaire to collect data from stationary SCFHs along the principal streets within North Dayi District. North Dayi District is one of the 18 administrative districts in the Volta Region, Ghana [ 40 ]. It shares boundaries with Kpando Municipal to the north, South Dayi District to the south, and Afadzato South District to the east. The entire residents of the North Dayi District are 39,913 covering 46.7% men and 53.3% women [ 40 ]. The people of the District constitute 1.9% of the total population of the Volta Region [ 40 ]. Farming is the foremost financial activity, making it one of the main sources of income in the district [ 40 ]. We carried out this study because of the recent cases of food-borne illness reported among the residents such as diarrhoea, cholera, and typhoid fever in the district [ 41 ].

Eligibility criteria

Stationary SCFHs who directly served already cooked food to customers and those who owned their outlets were included in the study. SCFHs who dissented to partake in the research were excepted including all assistants and helpers. The assistants and helpers were excluded because not all vendors had assistants or helpers and they tend to be more in numbers than the vendor-owners themselves. So for as not to allow bias in the results, we chose to sample only the vendor-owners. Moreover, vendor-owners tend to have direct responsibility for monitoring the food safety environment of their vending sites; hence, we chose to sample them as the focus of this study.

Sample size and sampling

Cochran’s formula Z 2 p  (1 −  p )/ e 2 [ 42 ] for unknown study populations was used. Since a similar study in the Volta Region of Ghana among the population subgroup is unavailable, 50% was used for response distribution, with 95% confidence level, and a margin of error of 5% for the populace, plus 10% non-response rate which gave us a sample size of 423.

Data collection tools

A structured questionnaire was designed based on different studies conducted globally [ 16 , 20 , 38 , 39 , 43 , 44 , 45 , 46 ]. Similar versions of the questionnaires were used in studies conducted in Ghana [ 47 , 48 , 49 ]. The instrument was distributed into 4 parts: socio-demographics, knowledge, attitude, and hygiene practices. The statements on KAP were adapted from the WHO’s Five Keys to Safer Food guidebook for food handlers [ 37 ]. The questionnaire was firstly designed in English, then converted to local dialects, and translated back to English to ensure reliability and simplicity of the question. Four professionals in the field of the study assessed the face and the content validity of the questionnaire. The questionnaire was pretested on 12 stationary SCFHs in Tanyigbe located 7 km from the study area. The pretesting findings were not added to the main study but were used to modify some questions to improve their clarity. The most pertinent modifications done on the study instrument were a cooked meal should stay hot more than 60°C before serving, putting uncooked and prepared meal separating prevent cross-contamination, and checking and dispose of meal that past their expiry date. The data were collected through trained research assistant-led interviews which lasted for about 25 min per respondent. The interviewer-administered questionnaire was given to the SCFHs who could read and write to answer by themselves while those SCFHs who could not read and write have been aided by the research assistants in answering the questionnaire.

Determination of knowledge, attitude, and hygiene practices on food safety

Section 2 of the questionnaire contained 10 structured questions on knowledge of food safety with 3 likely responses; “true”, “false”, and “do not know”. The questions precisely covered the respondents’ knowledge of individual cleanliness, food-borne illnesses, microbes, infection control, and sanitary practices. Each correct knowledge item reported was awarded a score of 1 point. Incorrect knowledge was awarded a 0 score (including “do not know”). In this study, if “true” is the correct answer, then “true” is score 1 point while “false” is score 0 point or otherwise reverse.

Queries relating to attitudes in the third segment of the questionnaire were designed to assess the knowledge of SCFHs on food wellbeing and hygiene. This part of the section assessed psychological state concerning views, opinion, morals, and characters to act in particular [ 21 , 48 ]. It contains 10 structured queries with 3 likely answers: “agree”, “disagree”, and “not sure”. Each correct attitude reported was awarded a score of 1 point while the other incorrect attitude option was rated a 0 score (including “not sure”). In this study, if “agree” is the correct answer, then “agree” is score 1 point while “disagree” is score 0 point or otherwise reverse.

• Hygiene practice

Section 4 of the questionnaire measured food hygiene and sanitation practices of SCFHs. It contained 10 structured queries with 2 likely answers: “yes” and “no”. Each correct hygiene practice reported was awarded a score of 1 point while incorrect hygiene practices reported were awarded a score of 0. This method of assessment was used in previous studies [ 28 ]. In this study, if “yes” is the correct answer, then “yes” is score 1 point while “no” is score 0 point or otherwise reverse.

The grouping method is appropriate and suitable for studies allied to the assessment “of food handlers” KAP of food safety and hygiene [ 27 , 28 , 34 , 46 , 47 , 50 , 51 , 52 ]. The knowledge and attitude questions with “do not know” or “not sure”, thus the third option, had been presented to enable simplicity of responding by SCFHs for fascinating for thoughts considered by an undecided or doubtfulness [ 28 ]. This third option “do not know” or “not sure” always scores a 0 point due to the cumulative percentage approach adapted which considers only the acceptable response or the correct answer [ 53 ]. The cumulative percentage scoring method of assessment considers only the acceptable answer and the total cumulative score is converted to 100% [ 53 ]. The cumulative scores below 70% of the acceptable responses on WHO’s Five Keys to Safer Food-related knowledge, attitude, and hygiene practices were considered as “poor”, and cumulative scores 70% and higher were considered as “good” [ 27 , 34 , 39 , 46 , 48 ].

Data analysis

Questionnaires were checked manually before entering into Microsoft Excel 2016 spreadsheet. Coding and analysis were done in IBM Statistical Package for Social Sciences (SPSS Inc., Chicago, USA; https://www.spss.com ) version 24.0. Categorical variables were expressed as frequency and percentage. The disparity between categorical variable groups was verified using the Fisher exact or chi-square test where appropriate. Significant parameters were used in bivariate and multivariate logistic regression models to calculate the power of the relationships observed. A p -value <0.05 was considered statistically significant.

Ethical consideration

Approval was sought from Ghana Health Service, North Dayi District Health Directorate, with the identity (NDDHD/GR/002/20) 15/07/2020. The research assistants introduced themselves and written informed permission was sought from the respondents. The research method was plainly explained to the respondents in their native dialects (English, Ewe, or Twi). Participants were identified by study numbers. The study numbers of the participants were kept in both locked files and secured computer files and accessible only to key investigators. All data were anonymized and unlinked to the respondents’ identities during the data analysis.

Demographic data

A total complete of 423 questionnaires were conveniently distributed for data collection based on the availability of SCFHs at their dedicated vending sites. Questionnaires of 407 were fully answered and collected from the respondents with a 96.2% (407/423) success rate. n = Z 2 p  (1 −  p )/ e 2   = 1.96 2 0.5 (1 − 0.5)/0.05 2 =384.16+38.416 =422.576. The majority ( n =343; 84.3%) of SCFHs were female, were between the age range of 26 and 35 years ( n =153; 37.6%), and were married ( n =311; 76.4%). Over one-third ( n =144; 35.4%) of SCFHs had attained secondary education. Most ( n =168; 41.3%) of SCFHs earned an average monthly income between GHc501 and GHc1000. Over half ( n =217; 53.3%) of SCFHs had 3–10 years of working experience. Regarding SCFH registered, n =297 (73.0%) reported that they have registered. More than half ( n =228; 56.0%) of SCFHs had not attended a food safety training course (Fig. 1 ).

Demographic data of respondents

Food safety knowledge

Almost all ( n = 381; 93.6%) of SCFHs knew about the washing of hands for 1 min using water and soap before touching food. The majority ( n =313; 76.9%) of SCFHs knew that similar chopping board should not be used for uncooked and prepared foods if it appears wash; n = 336 (82.6%) knew that cooked meal should stay hot before serving (more than 60°C); and n = 275 (67.6%) knew that excess meal should be kept at zone temperature and eat for the following mealtime. Most ( n =239; 58.7%) of SCFHs knew that uncooked meal should be kept individually from a prepared meal; n = 363 (89.2%) knew that treated water should be used for cooking; n = 363 (89.2%) knew that cockroach and house flies should not be allowed into the kitchen; and n = 274 (67.3%) knew that wiping cloths can spread microorganisms and cause disease. However, the majority ( n =235; 57.7%) of SCFHs did not know that food cooking utensils should not be cleaned using tap water only. Also, n = 202 (49.6%) of SCFHs did not know that fresh meat should not be stowed anyplace in the fridge once it is cool (Table 1 ).

Food safety attitude

The majority ( n =277; 68.1%) of SCFHs disagreed that regular hand cleaning throughout meal processing is needless; n = 323 (79.4%) agreed that cleaning kitchen shells lessen the danger of infection, and n = 355 (87.2%) agreed that putting uncooked and prepared meal separating stop infection. Below half ( n =181; 44.5%) of SCFHs agreed that they should be able to differentiate healthy diets and rotten food through eyeing; n =262 (64.4%) disagreed that using different knives and chopping materials for a fresh and prepared meal require more time; n = 366 (89.9%) agreed that they cough or sneeze inside the elbow if towel or paper not available; n = 291 (71.5%) agreed that checking meal for cleanliness and healthiness is important; and n =377 (92.6%) agreed that it is vital to dispose of meals that have gotten to expiring date. Nevertheless, n = 332 (81.6%) of SCFHs agreed that it is acceptable to use the same cloth for dusting and drying and n =217 (53.3%) disagreed that is unhealthy to allow prepared meal stay outside of the fridge for over 2 h (Table 2 ).

Food safety hygiene practice

The majority ( n =343; 84.3%) of SCFHs cleaned their fingers throughout meal cooking; n = 267 (65.6%) washed their cooking utensils used to cook a meal before using for a different meal; n =234 (57.5%) used different cooking bowls and chopping material if cooking a fresh and prepared meal; and n =359 (88.2%) dispersed uncooked and prepared meal before preservation. Also, n =278 (68.3%) keep prepared food at room temperature for 2 h when finished cooking; n =269 (66.1%) checked and disposed of meal past its expiry date; n =372 (91.4%) cleaned fresh food that needs no cooking before consumption; n =320 (78.6%) inspected if a meal is cooked by eyeing; and n =359 (88.2%) examined if a meal is grilled by touching it. Moreover, n =253 (62.2%) used similar kitchen cloth to clean shells and hands (Table 3 ).

SCFH knowledge, attitude, and hygiene practice on food safety classification

A high proportion ( n =274, 67.3%; n =237, 58.2%; and n =256, 62.9%) of SCFHs had good levels in knowledge, attitude, and hygiene practices on food safety (Fig. 2 ).

Levels of respondents’ knowledge, attitude, and hygiene practice on food safety

Association between knowledge, attitude, and hygiene practice and demographic data

Statistical significance was observed in the knowledge section among registered SCFHs ( p =0.031). None of the respondent’s socio-demographic data was statistically significant in the attitude section of food safety p < 0.05. The study found significant differences ( p <0.05) in the hygiene practice scores section with the educational status, average monthly income, registered SCFHs, and SCFHs completing food safety training course of food safety among SCFHs (Table 4 ). The odds ratio showed registered SCFHs were 1.6 times good at food safety knowledge likened to unregistered SCFHs [cOR=1.64 (95% CI 1.04–2.59), p =0.032]. The logistic regression analysis revealed that respondents who had secondary education were 4.1 times good at hygiene practice of food safety [aOR=4.06 (95% CI 1.63–10.11), p =0.003] compared to informal education. The respondents with average monthly income greater than GHc1500 were 4.9 times more likely to have good food safety and hygiene practices compared to those who earned less than Ghc500 average monthly income [aOR=4.89 (95% CI 1.56–15.34), p =0.006]. Meanwhile, registered SCFHs were 7.5 times more likely to have good food safety and hygiene practices compared to unregistered SCFHs [aOR=7.50 (95% CI 4.27–13.19), p <0.001]. The SCFHs who had completed a food safety training course were 6 times more likely to have good food safety and hygiene practices compared to those who had no such training [aOR=5.97 (95% CI 3.50–10.18), p <0.001] (Table 5 ).

Pearson correlation between knowledge, attitude, and hygiene practice toward food safety

The study revealed a positive correlation in the knowledge with the attitude outcomes sections (FSA) of food safety ( r =0.153, p =0.002) (Table 6 ).

The present study investigated knowledge, attitude, and hygiene practices of food safety on SCFHs in North Dayi District of Volta Region, Ghana. This study showed that the majority of SCFHs had good knowledge of food safety. This would help decrease the threat to contamination of foods, food poisoning, and FBDs to the consumers. Studies conducted in Saudi Arabia, Ethiopia, and Ghana have identified the importance of knowledge of food safety to SCFHs and have recommended training programmes on food safety to cultivate the knowledge into hygiene practices [ 14 , 27 , 34 ]. Our finding is inconsistent with previous studies done in Ethiopia and Jordan [ 38 , 45 ], however consistent with studies conducted in Ghana and Malaysia [ 47 , 54 ]. The possible reasons could be the type of food training courses received, the sample size, the scoring rubric applied, and understandings acquired on the subjects. This supported claims, creating an optimistic culture of food safety, inhibit food contamination if incorporated periodically [ 44 , 46 ]. This scenario affirms that the food safety training courses may remarkably enhance the knowledge of food handlers, especially concerning FBDs.

This study found that most of SCFHs knew about the washing of hands for 1 min using liquid and cleanser before touching food, which coincides with the study done in Iran [ 39 ]. The washing of hands with soap and water could reduce contamination of hands, cooking utensils, and cooking preparation surfaces leading to a substantive reduction of the risk of FBDs. Our finding does not corroborate with finding from a study done in Malaysia where a vast majority of SCFHs were knowledgeable of the 4th WHO Five Keys to Safer Food to keep the meal at healthy temperatures [ 20 ]. In our study, the SCFHs wrongly answered that fresh meat should be bestowed at any place in the fridge once it is cool. This misapplication of temperature could result in contamination and possibly proliferating of microbes in food. The reason is that appropriate temperatures can significantly lessen the risk at which foods will deteriorate, thereby preventing FBDs; hence for safety, foods must be held at an appropriate temperature sufficient to slow down the growth of microorganisms or kill microbes.

Attitude is one of the key elements that influence food safety and the practice and lessen the recurrence of food-related illnesses [ 51 ]. This study showed that most of SCFHs had a good attitude toward food safety. It means they understood their roles in food safety which was transmitted into attitude because they possibly serve as a vector for infectious pathogens which lead to food contamination. This agrees with studies conducted in Ghana and Haiti [ 48 , 55 ], but differs from a study done in Malaysia [ 36 ], where the majority of SCFHs had a poor attitude toward food safety. Possibly these could be due to the variances in socio-demographic characteristics, study population, and the study settings. These attitudinal variations could also be due to public reputation preference. Our study showed that visual checking was one of the key ways of differentiating healthy food from rotten ones, which concurs with a study conducted in Iran [ 39 ]. This finding is disturbing because the process of identifying food contamination cannot be performed by visual checking, since pathogens or toxins might be present in those foods without necessarily affecting SCFHs’ sensory aspects (smell, colour, or taste); therefore, food handlers who rely on visual checking for the identification of food contamination might expose consumers to an increased risk of contracting FBDs [ 39 , 56 ]. Therefore, the regulatory authorities must ensure that all SCFHs are trained professionally and certified.

The present study revealed a vast majority of SCFHs agreed that putting uncooked and prepared meal separating prevent cross-contamination, which corresponds to a study done in Haiti [ 55 ]. This act of putting fresh foods separating from cooked food could help prevent cross-contamination, which in turn may prevent infections from happening and halt FBDs. This is one of the highly endorsed public health measures to prevent cross-contamination [ 57 ]. This study found that almost all of SCFHs agreed that they coughed or sneezed into their elbows if a towel or paper is not available. Coughing and sneezing into the elbow or covering coughs and sneezes, and immediately washing the hands, could help to avert the spread of severe respiratory infections such as influenza and whooping cough. Our finding contradicts with other studies conducted in Malaysia and America; they reported that almost all respondents sneezed right away into their hands and never clean it [ 20 , 58 ]. This unpleasant attitude is harmful to the public since sneezing and coughing let out droplets of watery and perhaps transmittable microorganisms which can contaminate foods leading to FBDs.

Preservation of good sanitary behaviours is one of the goals for any food establishment, thereby its observance is vital to ensure safe meals for consumers [ 28 , 59 ]. The proportion of SCFHs in this current study with good hygiene practices of food safety corroborates with previous studies conducted in Saudi Arabia and Ghana [ 21 , 34 ]. This is an indication that SCFHs can be relied upon to act as the first-line responder to prevent several FBDs when they practice what they know. This would help reduce accidental contamination of foodstuffs due to improper management of cooking utensils and surroundings. Contradictory, in the present study, the scores obtained on the practices section were higher than hygiene practices of food safety reported in studies done in China and Nigeria [ 25 , 60 ]. The likely explanations of the difference reported could be as a result of the research population, the study cut-off used, the disparity in food safety courses, and differences in the law enforcement regimes. Our study revealed that the level of hygiene practices score was greater than the level of the attitude score attained by the SCFHs which corresponds to a study conducted in Malaysia [ 15 ]. The probable justification could be the SCFHs tend to provide responses they trust will create a good picture of their hygiene practices which account for the greater level score. The current study revealed that a vast majority of SCFHs washed their cooking utensils used to cook meals before using them for different meals, which is in line with a study done in Iran [ 39 ]. This act is acceptable because food handlers have been mostly identified as a significant vector for food contamination and responsible for FBDs [ 14 , 15 ]. Our study found that SCFHs practised wrongly by using similar kitchen cloth to clean shells and hands at the time which concurs with a study done in Malaysia [ 20 ]. The possible justification could be due to the non-compliance of the respondents to food safety training received. It could also be that they lack understandings of food safety education received. Hence, this displeasing practice may eventually result in contamination of hands and transfers of microorganisms to the consumers. This study showed that a vast majority of SCFHs cleaned fresh food that needs no cooking before consumption, which is in line with a study conducted in Malaysia [ 20 ]. This good hygiene practice is necessary to the elementary control of the spread of possibly FBDs.

Our study revealed a positive relationship between knowledge and the attitude of food safety which corresponds to earlier studies conducted in Malaysia, Iran, and Ghana [ 15 , 39 , 47 ]. Nevertheless, the strength of the correlation identified in the knowledge with the attitude scores of food safety was not strong, which implies that it is vital for the respective agency to monitor SCFH activities and enforce safety standards. Previous studies conducted in Malaysia and Iran found no significant relationship in the knowledge with the hygiene practices of food safety [ 20 , 39 ], which corresponds to our finding but contradicts with studies done in Malaysia and Ghana [ 15 , 47 ]. This result confirms the assertion that good knowledge does not affect the hygiene performance of food safety [ 61 ]. Hence, food handlers should be encouraged by food safety regulatory agencies to at least practise good hygiene irrespective of their levels of knowledge of food safety. In our study, no statistical association was found in the attitudes with the hygiene practice scores of food safety, which opposes earlier studies conducted in Malaysia, Iran, and Ghana [ 39 , 47 , 54 ]. These disparities could be due to their levels of knowledge of food safety and also possibly as a result of the kind of food safety training courses received. This present study found that registered SCFHs were more likely to have good food safety knowledge likened to unregistered SCFHs which is in line with earlier research in Lebanon [ 51 ] but differs in the study done in Malaysia [ 62 ]. The potential explanation is that maybe before SCFHs have been given their certification of registration, they probably have been taken through food safety training courses which provide them with adequate knowledge of food safety and offer them a good understanding of food poisoning, contamination, and hygiene. This shows the importance of registering food handlers who have successfully been through food safety training courses to acquire knowledge on food safety.

This study showed that the odds of good hygiene practices were higher among SCFHs who had secondary education likened to those with no formal education which is in line with a study conducted in Ethiopia [ 12 ]. In contrast to our findings, other studies conducted in Ethiopia and Ghana found SCFHs with primary education as more likely to have good hygiene practices of food safety likened to secondary education [ 27 , 34 ]. The possible reasons are because most food preparation skills, personal hygiene, and cleanliness are learned from friends, relatives, parents, and media but not necessarily from formal education. However, a lower level of education reduces awareness but the higher one gets educated the better the knowledge which affects their attitude and eventually may reflect into hygiene practices. It implies that food handlers should be encouraged to attain at least basic education before engaging into the cooking business, although it serves as the first sources of income for most uneducated people in the societies. Nevertheless, a study conducted in Ghana showed that regardless of educational background, the food safety actions of SCFHs remain an issue in many nations [ 48 ].

The present study showed that SCFHs who earned average monthly income above GHc1500 were more likely to have good hygiene practices compared to respondents who earned less than Ghc500. Our finding confirms a study conducted in Ethiopia and Jordan that found good hygiene practice among food handlers with higher monthly income than those with lower higher monthly income [ 27 , 63 ]. The possible justification is that SCFHs with high monthly income can afford to purchase items needed to establish themselves in hygienic environments and afford more employees to help in cleaning and waste treatment which could result in a reduction in food poisoning and cross-contamination. This means the high monthly income of food handlers determine their ways of hygiene practices, purchasing more cooking utensils for preparing different meals and managing their leftovers foods to prevent contamination.

The present study showed that registered SCFHs were in favour of good hygiene practices of food safety than the unregistered. The likely description is because of the food safety training courses they received before being registered as food handlers which provides them with an in-depth and comprehensive understanding of hygiene practices such as proper handling of food, personal cleanliness, and sanitation while preparing food. However, there is no research found relating registration of food handlers with hygiene practice scores; hence, the lack of the associated literature offers difficulties to compare our finding to collective results reasonably with concrete answered questions. Nonetheless, our finding shows the importance of registering food handlers after they have been through food safety training courses to encourage them to practise good hygiene.

This study found that SCFHs who have completed training courses on food safety were in favour of good hygiene practices of food safety likened to respondents who had not. Our finding asserts with previous studies done in Ethiopia, Malaysia, and Ghana [ 36 , 38 , 47 ]. The probable justification is that SCFHs who have completed food safety training courses had gained the talents and awareness necessary to handle food safely and sustain great ethics of self-cleanness and hygiene practices. Our finding affirms the assertion that training upsurges understanding of food safety which might reflect into hygiene practices [ 48 ]. Hence, a lack of or inadequate training of SCFHs on food safety may inadvertently result in poor hygiene practices, thereby encouraging food contamination [ 26 , 36 ]. This implies providing food safety training to food handles is important to keep consumers from food poisoning and other wellbeing dangers that could arise from eating unsafe food.

In this present study, it is significant to highpoint SCFHs’ knowledge, attitudes, and hygiene practices are unpredictable from the study conceded, though most of SCFHs properly responded by answering appropriately to related questions of WHO’s Five Keys to Safe Foods guidelines for food handlers. This theoretic-based assessment of the KAP method applied to assessed food handlers’ food safety KAP has some limitations. Firstly, the postulation that the received knowledge on food safety is translated into attitude is not entirely true. The existence of a social desirability bias could similarly have added to the discrepancy amid interview-responded KAP of SCFHs. Social desirability bias is the propensity of SCFHs to provide publically anticipated answers which will be regarded approvingly by people [ 64 ]. This proclivity has been shown by their descriptions and overrating socially anticipated KAP questions on food safety. Secondly, as we beforehand mentioned, the research assistants revealed their identities and the purpose of the study to the SCFHs; therefore, the SCFHs were mindful of the hygiene practices and the significance of observing them, but they remained keen to acknowledge their nonconformity and these could likely affect the self-reported hygiene practices. Thirdly, the unavailability of sufficient data from related studies in the district impedes an evaluative comparison of our findings to determine an improvement of food safety KAP among SCFHs; therefore, our findings ought to be interpreted with caution. However, due to the representative nature of the sample assessed, the findings of this study can be generalized to other SCFHs in the district. After all, it makes a substantial impact concerning food safety KAP in North Dayi District because it is the first study conducted in the district that presents an imperative foundation for design to increase food safety and hygiene practice in the district, region, and beyond.

Over half of the respondents had good levels of KAP of food safety. This study found a significant relationship in the knowledge and hygiene practice scores of food safety with SCFH registration. This shows the importance of strict enforcement of registration and certification of SCFHs by regulatory agencies as a means of protecting the consuming public. Therefore, the government agency through FDA should intensify the vitality of undertaking food safety training on WHO’s Five Keys to Safer Food by food handlers before being registered. Furthermore, the District Health Directorate should properly and effectively supervise food handlers engaging in cooking businesses to ensure they transmit the link between knowledge with the attitude of food safety into hygiene practice. Further studies should assess the kind of food safety training modules received and their impacts on the KAP of WHO’s Five Keys to Safer Foods as well as evaluating their hygiene practices with observational checklists.

Availability of data and materials

The datasets generated during and/or analyzed during the current study are not publicly available due to ethical consideration but are available from the corresponding author on reasonable request.

World Health Organization WHO. WHO estimates of the global burden of foodborne diseases: foodborne disease burden epidemiology reference group 2007-2015: World Health Organization; 2015.

Brandwagt D, van den Wijngaard C, Tulen AD, Mulder AC, Hofhuis A, Jacobs R, et al. Outbreak of Salmonella Bovismorbificans associated with the consumption of uncooked ham products, the Netherlands, 2016 to 2017. Eurosurveillance. 2018;23:317–35.

Google Scholar  

Navarro-Garcia F. Escherichia coli O104: H4 pathogenesis: an enteroaggregative E. coli/Shiga toxin-producing E. coli explosive cocktail of high virulence. Enterohemorrhagic Escherichia coli Other Shiga Toxin-Producing E coli. 2015;1:503–29.

Etter AJ, West AM, Burnett JL, Wu ST, Veenhuizen DR, Ogas RA, et al. Salmonella Heidelberg food isolates associated with a Salmonellosis outbreak have enhanced stress tolerance capabilities. Appl Environ Microbiol. 2019;85:1–22.

WPSE, Netty D, Sangaran G. Paper review of factors, surveillance and burden of food borne disease outbreak in Malaysia. Malaysian J public Heal Med. 2013;13:98–105.

Monney I, Agyei D, Owusu W. Hygienic practices among food vendors in educational institutions in Ghana: the case of Konongo. Foods. 2013;2(3):282–94. https://doi.org/10.3390/foods2030282 .

Fan YX, Liu XM, Bao YD. Analysis of main risk factors causing foodborne diseases in food catering business. Zhonghua Yu Fang Yi Xue Za Zhi. 2011;45:543–6.

Cheng Y, Zhang Y, Ma J, Zhan S. Food safety knowledge, attitude and self-reported practice of secondary school students in Beijing, China: a cross-sectional study. PLoS One. 2017;12:1–13.

Saad M, See TP, Adil MAM. Hygiene practices of food handlers at Malaysian government institutions training centers. Procedia-Social Behav Sci. 2013;85:118–27. https://doi.org/10.1016/j.sbspro.2013.08.344 .

Abdalla MA, Suliman SE, Bakhiet AO. Food safety knowledge and practices of street foodvendors in Atbara City (Naher Elneel State Sudan). African J Biotechnol. 2009;8:6967–71.

Ayeh-Kumi PF, Quarcoo S, Kwakye-Nuako G, Kretchy JP, Osafo-Kantanka A, Mortu S. Prevalence of intestinal parasitic infections among food vendors in Accra, Ghana. J Trop Med Parasitol. 2009;32:1–8.

Dagne H, Raju RP, Andualem Z, Hagos T, Addis K. Food safety practice and its associated factors among mothers in Debarq Town, Northwest Ethiopia: community-based cross-sectional study. Biomed Res Int. 2019;1:1–9.

Kuchenmüller T, Hird S, Stein C, Kramarz P, Nanda A, Havelaar AH. Estimating the global burden of foodborne diseases-a collaborative effort. Eurosurveillance. 2009;14:1–13.

Ayaz WO, Priyadarshini A, Jaiswal AK. Food safety knowledge and practices among Saudi mothers. Foods. 2018;7(12):193–208. https://doi.org/10.3390/foods7120193 .

Sani NA, Siow ON. Knowledge, attitudes and practices of food handlers on food safety in food service operations at the Universiti Kebangsaan Malaysia. Food Control. 2014;37:210–7. https://doi.org/10.1016/j.foodcont.2013.09.036 .

Oridota SE, Ochulo NF, Akanmu ON, Olajide TO, Soriyan OO. Food hygiene and safety practices of food handlers and its determinants in Lagos State. J Med Res Pract. 2014;3:37–41.

Chukuezi CO. Food safety and hyienic practices of street food vendors in Owerri, Nigeria. Stud Sociol Sci. 2010;1:50–7.

Dun-Dery EJ, Addo HO. Food hygiene awareness, processing and practice among street food vendors in Ghana. Food Public Heal. 2016;6:65–74.

Tefera T, Mebrie G. Prevalence and predictors of intestinal parasites among food handlers in Yebu town, southwest Ethiopia. PLoS One. 2014;9:1–13.

Soon JM, Wahab IRA, Hamdan RH, Jamaludin MH. Structural equation modelling of food safety knowledge, attitude and practices among consumers in Malaysia. PLoS One. 2020;15:1–12.

Sharif L, Al-Malki T. Knowledge, attitude and practice of Taif University students on food poisoning. Food Control. 2010;21(1):55–60. https://doi.org/10.1016/j.foodcont.2009.03.015 .

Kim J, Cho Y. Convergence evaluating food safety knowledge, attitude, and practice regarding food handler. J Korea Converg Soc. 2019;10:73–8.

Isoni Auad L, Cortez Ginani V, Stedefeldt E, Yoshio Nakano E, Costa Santos Nunes A, Puppin Zandonadi R. Food safety knowledge, attitudes, and practices of Brazilian food truck food handlers. Nutrients. 2019;11(8):1784–803. https://doi.org/10.3390/nu11081784 .

Zhao Y, Yu X, Xiao Y, Cai Z, Luo X, Zhang F. Netizens’ food safety knowledge, attitude, behaviors, and demand for science popularization by WeMedia. Int J Environ Res Public Health. 2020;17(3):730–40. https://doi.org/10.3390/ijerph17030730 .

Ma L, Chen H, Yan H, Wu L, Zhang W. Food safety knowledge, attitudes, and behavior of street food vendors and consumers in Handan, a third tier city in China. BMC Public Health. 2019;19(1):1128–39. https://doi.org/10.1186/s12889-019-7475-9 .

Tabit FT, Teffo LA. An assessment of the food safety knowledge and attitudes of food handlers in hospitals. BMC Public Health. 2020;20:311–22.

Lema K, Abuhay N, Kindie W, Dagne H, Guadu T. Food hygiene practice and its determinants among food handlers at University of Gondar, Northwest Ethiopia, 2019. Int J Gen Med. 2020;13:1129–37. https://doi.org/10.2147/IJGM.S262767 .

Yenealem DG, Yallew WW, Abdulmajid S. Food safety practice and associated factors among meat handlers in Gondar town: a cross-sectional study. J Environ Public Health. 2020;1:1–7.

Adane M, Teka B, Gismu Y, Halefom G, Ademe M. Food hygiene and safety measures among food handlers in street food shops and food establishments of Dessie town, Ethiopia: a community-based cross-sectional study. PLoS One. 2018;13:1–13.

Ababio PF, Lovatt P. A review on food safety and food hygiene studies in Ghana. Food Control. 2015;47:92–7. https://doi.org/10.1016/j.foodcont.2014.06.041 .

Yeleliere E, Cobbina SJ, Abubakari ZI. Review of microbial food contamination and food hygiene in selected capital cities of Ghana. Cogent Food Agric. 2017;3:1–12.

Ghana Standard Authority GSA. Personal communication with standard documentation department. 2013.

Sarkodie NA, Bempong EK, Tetteh ON, Saaka AC, Moses GK. Assessing the level of hygienic practices among street food vendors in Sunyani township. Pakistan J Nutr. 2014;13(10):610–5. https://doi.org/10.3923/pjn.2014.610.615 .

Odonkor ST, Kurantin N, Sallar AM. Food safety practices among postnatal mothers in Western Ghana. Int J Food Sci. 2020;1:1–10.

Monney I, Agyei D, Ewoenam BS, Priscilla C, Nyaw S. Food hygiene and safety practices among street food vendors: an assessment of compliance, institutional and legislative framework in Ghana. Food public Heal. 2014;4:306–15.

Rahman M, Arif MT, Bakar K, bt Tambi Z. Food safety knowledge, attitude and hygiene practices among the street food vendors in Northern Kuching city, Sarawak. Borneo Sci. 2012;31:95–103.

World Health Organization WHO. Five Keys to Safer Food Manual; Department of Food Safety, Zoonoses and Foodborne Disease. 2006; www.who.int/entity/foodsafety/ .

Azanaw J, Gebrehiwot M, Dagne H. Factors associated with food safety practices among food handlers: facility-based cross-sectional study. BMC Res Notes. 2019;12(1):683–9. https://doi.org/10.1186/s13104-019-4702-5 .

Fariba R, Gholamreza JK, Saharnaz N, Ehsan H, Masoud Y. Knowledge, attitude, and practice among food handlers of semi-industrial catering: a cross sectional study at one of the governmental organization in Tehran. J Environ Heal Sci Eng. 2018;16(2):249–56. https://doi.org/10.1007/s40201-018-0312-8 .

Ghana Statistical Service GSS. Population and housing census 2010 district and analytical report. 2010.

GHS GHS. Annual report, Ghana Health Service: GHS; 2020.

Cochran WG. Sampling technique. Third edit. New York: John Wiley & Sons; 1977.

Byrd-Bredbenner C, Berning J, Martin-Biggers J, Quick V. Food safety in home kitchens: a synthesis of the literature. Int J Environ Res Public Health. 2013;10(9):4060–85. https://doi.org/10.3390/ijerph10094060 .

Hashanuzzaman M, Bhowmik S, Rahman MS, Zakaria MUMA, Voumik LC, Mamun A-A. Assessment of food safety knowledge, attitudes and practices of fish farmers and restaurants food handlers in Bangladesh. Heliyon. 2020;6:1–8.

Osaili TM, Jamous DOA, Obeidat BA, Bawadi HA, Tayyem RF, Subih HS. Food safety knowledge among food workers in restaurants in Jordan. Food Control. 2013;31(1):145–50. https://doi.org/10.1016/j.foodcont.2012.09.037 .

Soares LS, Almeida RCC, Cerqueira ES, Carvalho JS, Nunes IL. Knowledge, attitudes and practices in food safety and the presence of coagulase-positive staphylococci on hands of food handlers in the schools of Camaçari, Brazil. Food Control. 2012;27(1):206–13. https://doi.org/10.1016/j.foodcont.2012.03.016 .

Amegah KE, Addo HO, Ashinyo ME, Fiagbe L, Akpanya S, Akoriyea SK, et al. Determinants of hand hygiene practice at critical times among food handlers in educational institutions of the Sagnarigu municipality of Ghana: a cross-sectional study. Environ Health Insights. 2020;14:1–10.

Akabanda F, Hlortsi EH, Owusu-Kwarteng J. Food safety knowledge, attitudes and practices of institutional food-handlers in Ghana. BMC Public Health. 2017;17(1):40–9. https://doi.org/10.1186/s12889-016-3986-9 .

Apanga S, Addah J, Sey DR. Food safety knowledge and practice of street food vendors in rural Northern Ghana. Food Public Heal. 2014;4:99–103.

Adesokan HK, Akinseye VO, Adesokan GA. Food safety training is associated with improved knowledge and behaviours among foodservice establishments’ workers. Int J Food Sci. 2015;1:1–8.

Bou-Mitri C, Mahmoud D, El Gerges N, Jaoude MA. Food safety knowledge, attitudes and practices of food handlers in Lebanese hospitals: a cross-sectional study. Food Control. 2018;94:78–84. https://doi.org/10.1016/j.foodcont.2018.06.032 .

Derso T, Tariku A, Ambaw F, Alemenhew M, Biks GA, Nega A. Socio-demographic factors and availability of piped fountains affect food hygiene practice of food handlers in Bahir Dar Town, northwest Ethiopia: a cross-sectional study. BMC Res Notes. 2017;10(1):628–35. https://doi.org/10.1186/s13104-017-2965-2 .

Al RA. On the contribution of student experience survey regarding quality management in higher education: an institutional study in Saudi Arabia. J Serv Sci Manag. 2010;3:464–9.

Siau AMF, Son R, Mohhiddin O, Toh PS, Chai LC. Food court hygiene assessment and food safety knowledge, attitudes and practices of food handlers in Putrajaya. Int Food Res J. 2015;22:1843–54.

Samapundo S, Climat R, Xhaferi R, Devlieghere F. Food safety knowledge, attitudes and practices of street food vendors and consumers in Port-au-Prince, Haiti. Food Control. 2015;50:457–66. https://doi.org/10.1016/j.foodcont.2014.09.010 .

Murray R, Glass-Kaastra S, Gardhouse C, Marshall B, Ciampa N, Franklin K, et al. Canadian consumer food safety practices and knowledge: foodbook study. J Food Prot. 2017;80(10):1711–8. https://doi.org/10.4315/0362-028X.JFP-17-108 .

Zhang H, Lu L, Liang J, Huang Q. Knowledge, attitude and practices of food safety amongst food handlers in the coastal resort of Guangdong, China. Food Control. 2015;47:457–61.

Berry TD, Fournier AK. Examining university students’ sneezing and coughing etiquette. Am J Infect Control. 2014;42(12):1317–8. https://doi.org/10.1016/j.ajic.2014.09.003 .

Khanal G, Poudel S. Factors associated with meat safety knowledge and practices among butchers of Ratnanagar municipality, Chitwan, Nepal: a cross-sectional study. Asia Pacific J Public Heal. 2017;29(8):683–91. https://doi.org/10.1177/1010539517743850 .

Faremi FA, Olatubi MI, Nnabuife GC. Food safety and hygiene practices among food vendors in a Tertiary Educational Institution in South Western Nigeria. Eur J Nutr Food Saf. 2018;8(2):59–70. https://doi.org/10.9734/EJNFS/2018/39368 .

Fadaei A. Assessment of knowledge, attitudes and practices of food workers about food hygiene in Shahrekord restaurants, Iran. World Appl Sci J. 2015;33:1113–7.

Radu S, Othman M, Toh PS, Chai LC. Assessment of knowledge, attitude and practices concerning food safety among restaurant workers in Putrajaya, Malaysia. Food Sci Qual Manag. 2014;32:20–7.

Osaili TM, Al-Nabulsi AA, Krasneh HDA. Food safety knowledge among foodservice staff at the universities in Jordan. Food Control. 2018;89:167–76. https://doi.org/10.1016/j.foodcont.2018.02.011 .

Jespersen L, MacLaurin T, Vlerick P. Development and validation of a scale to capture social desirability in food safety culture. Food Control. 2017;82:42–7. https://doi.org/10.1016/j.foodcont.2017.06.010 .

Download references

Acknowledgements

Not applicable.

Author information

Authors and affiliations.

Department of Epidemiology, School of Public Health, Nantong University, 9 Seyuan Road, Nantong, Jiangsu, China

Lawrence Sena Tuglo, Zhongqin Pan & Minjie Chu

Department of Nutrition and Dietetics, School of Allied Health Sciences, University of Health and Allied Sciences, Ho, Ghana

Percival Delali Agordoh

North Dayi District Health Directorate, Volta Region, Ghana Health Service, Accra, Ghana

David Tekpor & Gabriel Agbanyo

You can also search for this author in PubMed   Google Scholar

Contributions

MC and PDA conceived and designed the study. LST drafted the manuscript. DT and GA coordinated the data collection. ZP participated in the data collection and contributed to data analysis and interpretation. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Minjie Chu .

Ethics declarations

Ethics approval and consent to participate.

Approval was sought from Ghana Health Service, North Dayi District Health Directorate, with the identity (NDDHD/GR/002/20) 15/07/2020. Written informed permission was sought, and the research method was plainly explained to the respondents in their native dialects (English, Ewe, or Twi).

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Tuglo, L.S., Agordoh, P.D., Tekpor, D. et al. Food safety knowledge, attitude, and hygiene practices of street-cooked food handlers in North Dayi District, Ghana. Environ Health Prev Med 26 , 54 (2021). https://doi.org/10.1186/s12199-021-00975-9

Download citation

Received : 22 February 2021

Accepted : 19 April 2021

Published : 03 May 2021

DOI : https://doi.org/10.1186/s12199-021-00975-9

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Food safety
• Street-cooked food handlers

Environmental Health and Preventive Medicine

ISSN: 1347-4715

• General enquiries: [email protected]

• Open access
• Published: 22 December 2022

Food safety practice and its associated factors among food handlers in food establishments of Mettu and Bedelle towns, Southwest Ethiopia, 2022

• Sanbato Tamiru 1 ,
• Kebebe Bidira 1 ,
• Tesema Moges 2 ,
• Milkias Dugasa 1 ,
• Bonsa Amsalu 1 &
• Wubishet Gezimu 1  

BMC Nutrition volume  8 , Article number:  151 ( 2022 ) Cite this article

4806 Accesses

5 Citations

Metrics details

Food safety and hygiene are currently a global health concern, especially in unindustrialized countries, as a result of increasing food-borne diseases (FBDs) and accompanying deaths. It has continued to be a critical problem for people, food companies, and food control officials in developed and developing nations.

The objective of the study was to assess food safety practices and associated factors among food handlers in food establishments in Mettu and Bedelle towns, south-west Ethiopia, 2022.

A community-based cross-sectional study was conducted from February to March 2022, among 450 randomly selected food handlers working in food and drink establishments in Mettu and Bedelle towns, Southwest Ethiopia. Data was collected using an interviewer-administered structured questionnaire. The data was coded and entered into Epi Data version 3.1 before being exported to SPSS version 20 for analysis. Both bivariate and multivariable logistic regression models were fitted. An adjusted odds ratio and a 95% confidence level were estimated to assess the significance of associations. A p -value of < 0.05 was considered sufficient to declare the statistical significance of variables in the final model.

A total of 450 food handlers participated in the study, making the response rate 99.3%. About 202 (44.9%) of respondents had poor practices in food safety. Lack of supervision (AOR = 6.2, 95% CI: 3.37, 11.39), absence of regular medical checkups (AOR = 1.98; 95% CI: 1.14, 3.43), lack of knowledge of food safety practices (AOR =2.32; 95% CI: 1.38, 3.89), availability of water storage equipment (AOR =0.37; CI: 0.21, 0.64), and unavailability of a refrigerator (AOR =0.24; 95% CI: 0.12) were factors significantly associated with food safety practices.

The level of poor food safety practices was remarkably high. Knowledge of food safety, medical checkups, service year as food handler, availability of water storage equipment, availability of refrigerator, and sanitary supervision were all significantly associated with food safety practice. Hence, great efforts are needed to improve food safety practices, and awareness should be created for food handlers on food safety.

Peer Review reports

Introduction

Food safety is described as the circumstance and control required to ensure the safety, wholesomeness, and suitability of the food during its production and consumption. It is the primary public health concern for many countries, which is essential to prevent foodborne illness and enhance the well-being of humans [ 1 , 2 ]. Food safety and hygiene are currently a global health concern, particularly in developing countries, as a result of increasing food-borne diseases (FBDs) and accompanying deaths, and they also continue to be a critical problem in developed and developing nations for people, food companies, and food control officials [ 2 ].

Food-borne diseases (FBD) are associated with outbreaks, threaten global public health security, and have become an international concern as a growing public health issue [ 3 ]. According to the World Health Organization (WHO), FBDs in developing nations are serious because of bad hygienic food handling methods, poor understanding, and the absence of infrastructure. This is the result of poor use of food handling and sanitation practices, inadequate food safety laws, weak regulatory systems, and a lack of financial resources [ 4 , 5 ].

Findings of different studies showed that there are relatively few food safety problems in some Asian countries like Indonesia, Jordan, and Saudi Arabia, which ranged from 10 to 19.31%, respectively [ 6 , 7 ]. But when we look at the findings of the study conducted in Malaysia, the magnitude of poor food safety practices was about 41.7% [ 1 ]. A study conducted in some parts of the country revealed that there is a high magnitude of food safety problems in food and drink establishment centers, ranging from 46.3 to 72.67% [ 3 , 8 , 9 ].

WHO disclosed that 1 in 10 individuals worldwide is sick from foodborne illnesses secondary to unsafe food practices and the use of contaminated foods [ 10 ]. Food safety practices are worse in developing countries, including Ethiopia; according to previous studies conducted in Addis Ababa and other areas of the country, less than half of food handlers have maintained satisfactory safety practices in handling food in the studied food establishments [ 3 , 8 , 9 ].

Foodborne diseases are prevalent in Ethiopia; the country’s annual incidence of foodborne illnesses ranged from 3.4 to 9.3% [ 3 ]. Food safety practices also have economic implications. The effects of food-related illness expenditures on hospital treatments are about US$ 110 billion annually in developing countries, which results in decreased production [ 11 ]. Several factors, like prevailing poor food handling and sanitation practices, inadequate food safety training, weak regulatory systems, a lack of financial resources, low educational status, and a lack of knowledge, have been identified as affecting food safety [ 12 ].

Efforts have been made globally by preparing a food safety guideline with the help of the World Health Organization. Similarly, in Ethiopia, significant work has been done with regards to food safety by preparing a national food safety policy and guidelines and assigning a regulatory department in the health office at different levels, though people are still suffering from morbidities and mortalities related to food-borne diseases. This is mainly attributed to food safety practices [ 3 , 13 ]. Only a few studies have been conducted in Ethiopia with regard to food safety practices. Hence, the purpose of this study was to assess food safety practices and associated factors among food handlers in the food establishment centers of Mettu and Bedelle towns.

Study design, period, and area

A community-based cross-sectional study was conducted from February 21 to March 21, 2022, in Mettu and Bedelle towns. The two towns are located in the Oromia Regional State of southwest Ethiopia. Mettu is the capital of the Ilubabor Zone, and Bedelle is the capital of the Buno Bedelle Zone. Mettu and Bedelle towns are located about 600 and 480 km southwest of Addis Ababa, respectively. The two towns are home to different institutions and factories like Mettu University, Mettu Karl Comprehensive Specialized Hospital, Bedelle General Hospital, Bedelle Brewery Factory that provide services for a large number people in the southwest region of the country. There were 188 food establishments and 1015 food handlers in the study area, according to data gathered from the trade and industry bureaus of the two towns.

Populations and eligibility criteria

All food handlers who worked in food and drink establishments in Mettu and Bedelle towns were considered the source population, whereas all selected food handlers who worked in selected food and drink establishments in the two towns were study participants in this study.

Food handlers working in preparation, cleaning, and service areas of food establishments at the time of the study were included in the study. However, food handlers who were not available during the data collection period and who could not give a response due to severe illness were excluded from the study.

Sample size determination and sampling procedure

The sample size was determined using a single population proportion formula:

Where Z = 1.96, the confidence limits of the survey result (value of Z at α/2 or critical value for normal distribution at 95% confidence interval).

p  = 0.5 (50%), the population proportion of food safety practices from study conducted in Fiche town [ 5 ].

d = 0.05, the desired precision of the estimate

So the calculated sample size was, \(n={(1.96)}^2\frac{\left(0.5\ast 0.5\right)}{0.05^2}=384\)

Since the total number of food handlers in the study area was less than 10,000, we have utilized correction formula, that gives nf =288. After adding a 5% non-response rate and a design effect of 1.5, the final sample size of 453 was used for this study.

The list of existing food establishments and the number of food handlers currently working in food establishments were obtained from Mettu and Bedelle towns’ Trade and Industry Office. Then, food establishments for this study were randomly selected from a total list of food establishments. Next, study participants were proportionately allocated to each selected food establishment based on the number of food handlers. Then, an updated list of food handlers was taken from the manager or owner of the selected establishment. Finally, study participants were selected using a simple random method from each establishment.

Study variables

The dependent variable of this study was food safety practice, and the independent variable includes socio-demographic factors (educational level, age, gender, marital status, and work experience), institutional factors (training, supervision, and availability of guidelines for food safety), health-related factors (medical check-ups and sick leave during illness), knowledge-related factors (knowledge of methods to prevent contamination and knowledge of food safety practices), and sanitary facility-related factors (three-compartment dishwashing systems, refrigerators in the kitchen, and water supply).

Data collection tools and procedure

Data were collected using an interviewer-administered standardized questionnaire adapted and modified from previously published studies [ 3 , 8 , 9 , 13 ]]. The questionnaire was structured into six parts: socio-demographic parts with six questions, food safety knowledge with nine questions, basic sanitary facilities with seven questions, institutional factors with four questions, health-related with two questions, and food safety practice with twelve questions.

Food safety knowledge was assessed using nine closed-ended questions with two possible answers: “yes” or “no.” The questions mainly focus on the personal hygiene of food handlers, temperature control, cross-contamination, food storage, and equipment hygiene. In assessing knowledge, one score was given for every correct answer and zero score for incorrect answers or unanswered questions. Then, the responses to these questions were added together to generate a knowledge score. Food handlers who obtained a total score greater than the mean value were considered to have good food safety knowledge, and those who had scores less than the mean value were considered to have “poor food safety knowledge.”

Food safety practices were also assessed using 12 closed-ended questions with two possible answers: “yes” or “no.” One score was given for every standard practice and zero for every unsafe practice. Food handlers with a total score greater than the mean were considered to have “good food safety practices,” while those with a score less than the mean were considered to have “poor food safety practices.” The data was collected by three diploma nurses, and the overall data collection processes were supervised by one health officer after two days of training.

Data quality assurance

The quality of the data was ensured through all data collection tools and was translated into the local language and back-translated to English by language experts to ensure its consistency. Training of data collectors and supervisors was conducted to enable them to acquire the basic skills necessary for data collection and supervision, respectively. A pre-test was done on 5% of the sample in Gore town, and based on the results of the pre-test, necessary modifications were made. After data collection, the completeness of the data was checked by the principal investigator ahead of data entry. Incomplete and inconsistent questionnaires were excluded from the analysis.

Data analysis

The collected the data was curated according to the study objectives. The coded responses were entered into EpiData and exported to SPSS for analysis. A descriptive analysis was used to describe the percentages and number of distributions of the respondents by socio-demographic characteristics and other relevant variables in the study. A binary logistic regression analysis was performed on the independent variables and their proportions, and a crude odds ratio was computed against the outcome variable. The independent variables with a p -value less than 0.25 were entered into the multivariable logistic regression analysis to control for potential confounders and identify significant factors associated with outcome variables. Finally, a p -value of less than 0.05 at the 95% CI was used to claim statistical significance.

Ethics and approval processes

The ethical clearance letter was obtained from ethical committee of Mettu University, college of health science before conducting study. After the interviewer read and clearly explained the study’s benefits and risks, a written consent was obtained from the study participants. Then literate participants signed, whereas uneducated participants put their fingerprints on the consent form to shown their willingness to participate. Confidentiality of the data was maintained at all times.

Socio-demographic characteristics of food handlers

In this study, a total of 450 food handlers participated out of a total of 453 with a response rate of 99.3%. The mean age of the participants was 29.3 years (SD = 5.28). The majority (54%) of food handlers were female. One hundred ninety-one (42.4%) of them attended secondary education, while only nine (2%) of them had least a higher education qualification. More than half (62.2%) of food handlers were married. Regarding service year as food handler, about 181 (40.2%) of respondents had worked for 2–4 years [Table  1 ].

Practice of food handlers on food safety

Among the 450 total food handlers, 417 (92.7%) of them were not checking the temperature of food. The majority, 333 (74%) of food handlers, did not wash their hands after sneezing. Two hundred and eleven (46.7%) participants did not wear hair covers. About 10.2% of food handlers did not trim their fingernails. Majority, 387(86%) of the participants, did wash their hands after touching unwrapped food, whereas 366 (81.3) of them wash their hands before touching cooked food. Moreover, 145 (32.2%) of participants did not use separate utensils for raw and cooked foods [Table  2 ].

Level of food safety practice

In general, out of all participants, 202 (44.89%) had poor food safety practices, while 248 (55.1%) had good food safety practices [Fig.  1 ].

Overall food safety practice of food handlers working in food and drink establishment in Mettu & Bedelle towns south west Ethiopia, 2022 ( n  = 450)

Factors associated with food safety practice

In the bivariate analysis, variables like sanitary inspection, medical checkup, food safety knowledge, the presence of a refrigerator, the service year as a food handler, the presence of guidelines or guiding instructions, and the unavailability of water storage equipment were shown to be associated with the outcome variable. In the multivariable logistic analysis, the variables sanitary inspection (AOR = 6.2; 95% CI: 3.37, 11.39), medical checkup (AOR = 1.98; 95% CI: 1.14, 3.43), knowledge of food safety practices (AOR = 2.32; 95% CI: 1.38, 3.89), the presence of a refrigerator (AOR = 0.24; CI: 0.12, 0.45), and availability of water storage equipment (AOR = 0.37; CI: 0.12, 0.45) were found to be significantly associated with food safety practices.

The study revealed that food handlers with a poor level of knowledge were 2.32 times more likely to have poor food safety practices than those with a good level of knowledge (AOR = 2.32; 95% CI: 1.38, 3.89). The likelihood of having poor food safety practices among food handlers who did not have regular medical checkups was nearly two times higher than among food handlers who have regular medical checkups (AOR = 1.98; 95% CI: 1.14, 3.43). Moreover, poor food safety practice was 6.2 times higher among non-supervised food handlers as compared to their counterparts (AOR = 6.2; 95% CI: 3.37, 11.39) [Table  3 ].

Ensuring optimal food safety practices is still a major global challenge, particularly in developing countries like Ethiopia. This has in turn resulted in a high prevalence of FBD [ 3 ]. This study aimed to assess food safety practices and its associated factors among food handlers in food establishments of Mettu and Bedelle towns, Southwest Ethiopia.

The findings of the present study showed that 44.9% (CI: 40.29, 49.49) of participants had poor food safety practices. This finding is higher than studies conducted in Indonesia (10%) [ 2 ], Saudi Arabia (19.3%) [ 6 ], Nigeria (30.5%), [ 14 ], Arba Minch town, Southern Ethiopia (32.6%) [ 15 ], Dessie town, Northern Ethiopia (28%) [ 16 ], and Assosa Western Ethiopia [ 17 ]]. The variation might be due to differences in study settings and food handler’s socio-demographic profile. But it was lower than studies conducted in Fiche (50%) [ 3 ], and Gondar town (53.3%) [ 12 ]. The possible reason for discrepancies might be the difference in the study design, cutoff points, and year of study. However, the present finding was comparable with studies conducted in Debra Markos town (46.3%) [ 9 ], Woldia town, Northeast Ethiopia(46.5) [ 18 ], Dangila town, North West Ethiopia(47.5%) [ 19 ] and Batu town Central Ethiopia [ 20 ].

Regarding factors associated with poor food safety practice, this study revealed that; a lack of regular medical checkup was significantly associated with poor food safety practices. The likelihood of having poor food safety practices among food handlers who did not have regular medical checkups was nearly two times higher than that of those food handlers who have regular medical checkups. This finding was supported by a study conducted in Fiche, Gondar towns, and Dessie town [ 3 , 12 , 17 ]. This might be due to behavioral change following counseling given during a medical checkup.

The study revealed that sanitary inspection is significantly associated with food safety practice. Poor food safety practice was 6.2 times higher among non-supervised food handlers as compared to their counterparts. This finding is supported by a previous study conducted in Arba Minch town of Southern Ethiopia [ 15 ].

In the present study, knowledge of food safety was significantly associated with food safety practices. Food handlers with a poor level of food safety knowledge were 2.33 times more likely to have poor food safety practices than those with a good level of knowledge. This study is supported by cross-sectional studies conducted in Gondar city, Debra Marcos town, Dangila town, Northern Ethiopia, and Batu town, Central Ethiopia [ 9 , 12 , 19 , 20 ].

There was a significant association between food safety practices and sanitary inspection. The probability of having poor food safety practices was higher among food handlers who were not supervised than their counterparts. The present finding was supported by a study conducted in Assosa and Gondar city, Woldia town [ 12 , 17 , 18 ]. This might be due to the effect of advice and feedback given to supervised food handlers, managers, and the owners during an inspection.

The probability of having poor safety practices was 62.7% less likely among food handlers working in establishments having water storage equipment as compared to their counterparts. This might be due to easy access of water to cleansing. This finding was supported by a community based cross sectional study conducted in the Bole sub-city of Addis Ababa[ [ 8 ].

Moreover, the service year as a food handler was also significantly associated with food safety practices. The probability of having poor food safety practices among food handlers with 2–4 and 5–7 years of service was 96.8 and 88.5% less likely, respectively, as compared to those food handlers with a service year of less than 2 years. The finding was supported by a study conducted in Fiche and Debra Marcos town [ 3 , 9 ]. This might be due to the positive effect of adaptation to a specific working environment and sharing experience from coworkers.

Limitations of the study

The study was based on reported rather than observed practices related to food safety. Therefore, there was a risk that respondents may report what was expected of them but practice may be different. In addition, lack of universal consensus on the definition of good or poor practice was a challenge in the study. Furthermore, parasitic and microbiological laboratory investigations were not considered in this study.

The level of poor food safety practices was remarkably high in the study area. Almost all food handlers did not use thermometers to check the temperature of the food. More than one-third of them were not using separate utensils for raw and cooked foods. Nearly half of food handlers did not use hair covers, and three-fourths of them did not practice sanitizing or washing their hands after sneezing prior to touching foods. Generally, there is an increased risk of FBD in association with the identified poor food safety practices. Factors like sanitary inspection, medical checkup, food safety knowledge, availability of refrigerator, service year as food handlers, and availability of water storage were identified as having significant associations with the identified poor level of food safety practice. Therefore, there is need to invest much more in food safety practices, and special emphasis should be given to food safety in order to reduce the risk of FBD and ensure optimal food safety practices.

Recommendation

To improve food safety practices, all concerned bodies should play their roles. Food handlers should have regular medical checkups, maintain good hygiene, try to improve their knowledge and practice of food safety, and play a crucial role in ensuring good food safety practices. Food handlers should also use separate utensils for raw and cooked foods to reduce cross-contamination. Food establishment owners should avail themselves of equipment like refrigerators and water storage that can help ensure food safety by preventing spoilage and contamination.

Healthcare professionals and food professionals in collaboration need to conduct on-site supervision, inspect the hygiene of food handlers, and observe the way they are working towards food safety practices. They should conduct strict sanitary supervision on a regular basis and take timely corrective action (reward compliant food handler or constrain non-compliant handlers). In addition, they need to arrange for regular medical checkup of food handlers in collaboration with nearby medical facilities.

The trade and industry office should work in collaboration with health office and take food safety practices into consideration during the renewal of licenses of establishments, and the government or policy makers should enforce the implementation of HACCP as guiding instructions in all establishments as a mandatory requirement. Based on current findings, future researchers can conduct detailed investigations that are supported by microbial analysis and try to show a new approach to improving food safety practice.

Ethics statements

The study was carried out in accordance with the principles of the Declaration of Helsinki. The study was conducted after getting ethical approval and clearance from the institutional review board (IRB) of Mettu University. A supportive letter was taken from Mettu University and submitted to each hospital, and permission was obtained from each hospital. Participation was completely voluntary, with no economic or other motivation, and informed consent was obtained from the study participants. All participants were informed of the study’s purpose and given the right to respond fully or partially to the questionnaire. They also had the right to withdraw at any time. Furthermore, Participants who agreed to participate in the study were asked to sign informed consent forms. The privacy and identity of participants were protected, and participants’ confidentiality was also assured by omitting their names from the informed consent form.

Conflict of interest

The authors declare that they have no competing interests.

Availability of data and materials

All the data generated or analyzed during the current study are available from the corresponding author upon reasonable request.

Abd Lataf Dora-Liyana NA, Mahyudin MR, Ismail-Fitry AA-Z, Rasiyuddin H. Food safety and hygiene knowledge, attitude and practices among food handlers at boarding schools in the northern region of Malaysia. Soc Sci. 2018;8(17):238–66.

Google Scholar  

Organization WH. WHO estimates of the global burden of foodborne diseases: foodborne disease burden epidemiology reference group 2007-2015: World Health Organization; 2015.

Teferi SC, Sebsibe I, Adibaru B. Food safety practices and associated factors among food handlers of Fiche Town, North Shewa Zone, Ethiopia. Journal of environmental and public health. 2021;2021:6158769. https://doi.org/10.1155/2021/6158769 .

Article   Google Scholar  

Borchers A, Teuber SS, Keen CL, Gershwin ME. Food safety. Clinical reviews in allergy & immunology. 2010;39(2):95–141.

Article   CAS   Google Scholar  

Grace D. Food safety in developing countries: An overview. Hemel Hempstead, UK: Evidence on Demand . 2015; Available from https://hdl.handle.net/10568/68720 .

Ayaz WO, Priyadarshini A, Jaiswal AK. Food safety knowledge and practices among Saudi mothers. Foods. 2018;7(12):193.

Lestantyo D, Husodo AH, Iravati S, Shaluhiyah Z. Safe food handling knowledge, attitude and practice of food handlers in hospital kitchen. Int J Public Health Sci. 2017;6(4):324–30.

Abdi AM, Amano A, Abrahim A, Getahun M, Ababor S, Kumie A. Food hygiene practices and associated factors among food handlers working in food establishments in the Bole Sub City, Addis Ababa, Ethiopia. Risk Manag Healthc Policy. 2020;13:1861.

Alemayehu T, Aderaw Z, Giza M, Diress G. Food safety knowledge, handling practices and associated factors among food handlers working in food establishments in Debre Markos Town, Northwest Ethiopia, 2020: institution-based cross-sectional study. Risk Manag Healthc Policy. 2021;14:1155.

Reta MA. Lemma MT. Lemlem GA. Food handling practice and associated factors among food handlers working in food establishments in Woldia town, Northeast Ethiopia: Gemeda AA; 2020.

Yenealem DG, Yallew WW, Abdulmajid S. Food safety practice and associated factors among meat handlers in Gondar town: a cross-sectional study. Journal of Environmental and Public Health. 2020;2020:7421745.

Azanaw J, Gebrehiwot M, Dagne H. Factors associated with food safety practices among food handlers: facility-based cross-sectional study. BMC Research Notes. 2019;12(1):1–6.

Chekol FA, Melak MF, Belew AK, Zeleke EG. Food handling practice and associated factors among food handlers in public food establishments, Northwest Ethiopia. BMC Research Notes. 2019;12(1):1–7.

Iwu AC, Uwakwe KA, Duru CB, Diwe KC, Chineke HN, Merenu IA, et al. Knowledge, attitude and practices of food hygiene among food vendors in Owerri, Imo State, Nigeria. Occup Dis and Environ Med. 2017;5(01):11.

Legesse D, Tilahun M, Agedew E, Haftu D. Food handling practices and associated factors among food handlers in arba minch town public food establishments in Gamo Gofa Zone. South Ethiop Epidemiol (Sunnyvale). 2017;7(302):2161–1165.

Adane M, Teka B, Gismu Y, Halefom G, Ademe M. Food hygiene and safety measures among food handlers in street food shops and food establishments of Dessie town, Ethiopia: a community-based cross-sectional study. PloS one. 2018;13(5):e0196919.

W. AMaK. Food safety knowledge, Handling Practice and Associated Factors among Food Handlers of Hotels/Restaurants in Asosa Town, North Western Ethiopia. J Public Health Epidemiol. 2018;4(2):1051.

Reta MA, Lemma MT, Gemeda AA, Lemlem GA. Food handling practices and associated factors among food handlers working in public food and drink service establishments in Woldia town, Northeast Ethiopia. Pan Afr Med J. 2021:40.

Tessema AG, Gelaye KA, Chercos DH. Factors affecting food handling Practices among food handlers of Dangila town food and drink establishments, North West Ethiopia. BMC public Health. 2014;14(1):1–5.

Abe S, Arero G. Food handler’s safety practices and related factors in the public food establishments in Batu Town, Central Oromia. Ethiopia. Health. 2021;2(1):1–8.

Download references

Acknowledgements

We thank Mettu University for financial support. Again, our sincere appreciation goes to study participants, data collectors, and supervisors. Moreover, we would like to thank the Mettu and Bedelle towns’ trade and industry offices for provision of background information about the study population.

This research was funded by Mettu University with grant number of Meu/2021/210.

Author information

Authors and affiliations.

Department of Nursing, Mettu University, Mettu, Ethiopia

Sanbato Tamiru, Kebebe Bidira, Milkias Dugasa, Bonsa Amsalu & Wubishet Gezimu

Department of Public Health, Mettu University, Mettu, Ethiopia

Tesema Moges

You can also search for this author in PubMed   Google Scholar

Contributions

ST, KB, and TM participated in conceptualization of the study, methods, supervision, analysis, investigation, software, and writing of the first and final draft of the manuscript. MD, BA, and WG participated in the study methods, data curation, resource acquisition, and writing the final manuscript. Finally, all authors approved the last version of the manuscript to be published, and agreed to be accountable for all parts of the work.

Corresponding author

Correspondence to Sanbato Tamiru .

Ethics declarations

Ethics approval and consent to participate.

This study was approved by the Research Ethics Committee of Mettu University. All methods were conducted in accordance with the code of ethics outlined in the Declaration of Helsinki. After the interviewer read and clearly explained the study’s benefits and risks, a written consent was obtained from the study participants. Then literate participants signed, whereas uneducated participants put their fingerprints on the consent form to shown their willingness to participate. Confidentiality of the data was maintained at all times.

Consent for publication

Not applicable.

Competing interests

Additional information, publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1..

Annexe-1 Questionnaires and Consent forme.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Tamiru, S., Bidira, K., Moges, T. et al. Food safety practice and its associated factors among food handlers in food establishments of Mettu and Bedelle towns, Southwest Ethiopia, 2022. BMC Nutr 8 , 151 (2022). https://doi.org/10.1186/s40795-022-00651-3

Download citation

Received : 07 September 2022

Accepted : 15 December 2022

Published : 22 December 2022

DOI : https://doi.org/10.1186/s40795-022-00651-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Food safety
• Food handlers

BMC Nutrition

ISSN: 2055-0928

• General enquiries: [email protected]

• Research article
• Open access
• Published: 12 February 2021

Food safety knowledge, attitudes and practices of food handlers: A cross-sectional study in school kitchens in Espírito Santo, Brazil

• Alyne Gomes da Vitória 1 ,
• Jhenifer de Souza Couto Oliveira 1 ,
• Louise Caroline de Almeida Pereira 2 ,
• Carolina Perim de Faria 3 &
• Jackline Freitas Brilhante de São José   ORCID: orcid.org/0000-0002-6592-5560 3  

BMC Public Health volume  21 , Article number:  349 ( 2021 ) Cite this article

35k Accesses

17 Citations

1 Altmetric

Metrics details

The adoption and evaluation of good practices in food handling in food service are essential to minimizing foodborne diseases. The present study aimed to evaluate food safety knowledge, attitudes, and practices of food handlers in schools in Vitória, Brazil.

A cross-sectional study was carried out in the school food services of the municipal network of Vitória-ES. The sample of food handlers was obtained by convenience and comprised food handlers involved with preparation and other kitchen-related activities. The instrument consisted of a structured questionnaire with 36 six questions that included sociodemographic characteristics, knowledge, attitudes, and practices (KAP) related to good practices and food safety. The questionnaire was answered by 172 food handlers. Pearson correlation test, T-test, Tukey’s test and multiple linear regression analysis were conducted. Data entry and analysis were done using SPSS v.20 software.

Most of the participants were female (96.5%, n  = 166), were 40 to 49 years old (44.8%, n  = 78), attended high school (57.9%, n  = 99), had up to 5 years of experience in the role (39.5%, n  = 68). Some of them had participated at least 4 times in training (74.4%, n  = 128) of which the most recent session had occurred within 3 months (52.0%, n  = 44). The lowest score was obtained for knowledge (7.1 ± 1.22). All the models presented significant results for the F-test. This result show good model fit and results ranging from 1.5 to 2.5 on the Durbin Watson test of residual autocorrelation. The linear regression analysis allowed us to identify that the knowledge score increased with experience, but it was significant only for those who had spent up to 10 years in the role. The knowledge score was associated with experience and training time. Attitudes were significantly related to the schooling and training time. The increase in the classification of practices is shown only through a classification of attitudes.

Conclusions

Although the food handlers’ knowledge level in general was considered as sufficient, it was inferior to their scores for attitudes and practices regarding certain food safety concepts. Food safety training is ongoing in these units and covers the main aspects that favour the transformation of knowledge into appropriate attitudes and practices.

Peer Review reports

According to the World Health Organization (WHO), millions of people are affected annually by diseases associated with the consumption of contaminated food, particularly in developing countries. These illnesses mainly affect children and other vulnerable groups, such as pregnant women, the sick and the elderly [ 1 ].

In the Brazilian context, children’s vulnerability is linked to another concerning issue, according to data from the Ministry of Health, the fifth most frequent location of outbreaks of foodborne diseases (FDs) in nurseries and schools [ 2 ]. The adoption of correct food handling practices is recommended by the legislation in force and covers a series of determinations. Precautions in food handling are necessary and must be adopted by all food service facilities, including school kitchens, to minimize the risk of FD occurrence [ 3 ].

Considering these aspects, the evaluation of the factors involved in safe food production is of great importance. Good practices contribute to one principle of the National School Feeding Program (NSFP), which aims to meet the needs of students through the provision of healthy and safely handled food. It is one of the largest school food programs in the world and is the only such program with universal participation [ 4 ].

Quality control of school meals is imperative because dangers from different sources can cause contamination between the food preparation and distribution stages and culminate in the occurrence of FDs. FDs are a major consequence of the lack of sanitary control in food service environments [ 5 , 6 ].

Although food safety in food services is a relevant issue and measures are taken to guarantee food quality [ 7 , 8 , 9 ], studies conducted in different Brazilian locations have reported that food handlers’ behavior has an important influence on contamination and can reduce the quality of the final products [ 7 , 10 , 11 , 12 , 13 ]. Then, food handlers have different food safety knowledge levels, and sometimes, an adequate knowledge level does not translate into good hygienic practices when processing and handling food products [ 13 , 14 , 15 , 16 ]. Thus, training programs contribute to knowledge about food safety, although knowledge acquisition does not always result in positive changes in good handling practices [ 14 , 15 , 16 ]. Given food handlers’ role in improving hygiene and sanitation in School Feeding Service (SFS) and considering the vulnerability of the public served by NSFP, the present study aimed to verify the level of food safety knowledge, attitudes and practices (KAP) among food handlers in schools in Vitória, Brazil. We aimed to verify three hypotheses in this study: i) food handlers don’t have a satisfactory knowledge level; ii) food handlers don’t have a satisfactory attitudes and practices level; iii) sociodemographic variables are related with food handler’s knowledge, practices and attitudes.

Study design

A cross-sectional study was conducted to evaluate the KAP related to food safety through a specific questionnaire for food handlers. This work is part of a larger project entitled “Evaluation of the level of knowledge, attitudes and practices of food handlers in food services”, which was presented to and approved by the Municipal Secretary of Education (MSE) of Vitória-ES. Following this approval, invitation letters were e-mailed to school managers with the MSE’s authorization to commence the project. The managers were also contacted via telephone or in person for permission to visit the schools.

Study area, sample size and sampling

Data were collected at SFS from schools within the municipal network in Vitória, Espírito Santo, Brazil. There are 100 municipal schools in Vitória, Brazil and all were invited to participate in this study. The school units are distributed among nine administrative regions. The composition of the sample was determined by considering the total number of school units and the proportion of units in each administrative region. The participation of 50% of the schools in each region was required to demonstrate representativeness. Fifty-two eligible schools were sampled using simple cluster sampling; schools were stratified according to the regions of the municipality and randomly selected from each region. The municipal school units are distributed among nine administrative regions: Region 1 – Total = 8 ( n  = 4); Region 2 – Total = 15 ( n  = 8); Region 3 – Total 16 (n = 8); Region 4 – Total = 22 ( n  = 12); Region 5 – Total = 2 (n = 1); Region 6 – Total = 7 (n = 4); Region 7 – Total = 18 ( n  = 9); Region 8 – Total = 6 ( n  = 3); Region 9 – Total = 6 (n = 3). All administrative regions are located in the urban area and the region 5 and region 9 have the highest incomes in the city.

The sample of food handlers was obtained by convenience and comprised those carrying out food preparation and other kitchen-related activities in 52 municipal schools. All food handlers who were available at the time of collection in schools were invited to participate. Each school had 2 to 5 food handlers.

Instrument for data collection

The KAP questionnaire applied in this research was subjected to a reproducibility test given the limitations associated with the use of such instruments, such as imprecise answers and failure to understand the material. This process allows the reproducibility levels of a questionnaire to be determined, which leads to obtaining better quality data [ 17 ].

Test-retest reliability was determined with 29 food handlers from one food service unit and were not part of the research sample. The questionnaires were administered at the participants’ workplace, and the retest procedure took place 15 days after the first administration.

The instrument consisted of a structured questionnaire based on related studies [ 15 , 18 , 19 ]. The content related to KAP issues and the correct answers was determined considering the Brazilian resolution of good practices for food service [ 3 ], the Codex Alimentarius [ 20 ], and the five keys to safer foods established by the WHO [ 21 ] and adapted from Cunha et al. [ 15 ]. Additionally, six questions assessed the following sociodemographic characteristics of the handlers: age, sex, education, participation in food safety training and amount of experience as a food handler.

The KAP evaluation was organized into three blocks following Cunha, Stedefeldt & Rosso [ 15 ]. The block related to knowledge evaluation comprised 10 objective questions related to the daily practices of food preparation and addressing the concepts of personal hygiene, food hygiene, cross-contamination and the thawing of food. The three answer options were “yes”, “no” and “I do not know”.

The attitude assessment block included 10 questions related to the importance of hygiene procedures, food handlers’ responsibility for avoiding foodborne illnesses and the importance of ongoing training about food safety. In this block, attitude was considered a way of thinking that is reflected by a person’s behavior. The food handlers indicated their level of agreement on a three-point scale that reflected the following response options: “I agree,” “disagree,” and “I do not know.”

The last block of the questionnaire referred to the evaluation of self-reported practices and comprised 10 questions about daily practices that addressed the same themes as the knowledge block. A five-point rating scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often and 5 = always) was used to evaluate each practice. For practices that are considered inadequate, the scale was scored following an inverse order.

For the knowledge questions, one point was assigned for each correct answer; each incorrect or “I do not know” answer received zero points. The range of possible scores for the knowledge block was 0 to 10 points. The possible score for the attitude questions ranged from 0 to 100 points. For the practice’s questions, the possible score was from 10 to 50. For the evaluation of each block based on the sum of the final scores for each block, an adequate grade was 70% or higher based on a study by Soares et al. [ 19 ]. Completing the questionnaires took approximately 15 min and was performed by the participants themselves in the presence of the researchers. In situations of doubt or reading difficulties, the researchers read the questions to avoid providing further explanations that would influence the answers.

Data analysis

Data were tabulated in Microsoft Office Excel spreadsheets and analyzed using IBM SPSS Statistics software, version 22 (IBM Corporation, Armonk, NY, USA).

Questionnaire reproducibility test

After an exploratory analysis of the data, reproducibility was assessed using the intraclass correlation coefficient and interpreted according to the criteria proposed by Cicchetti [ 22 ] using the following scale: poor (< 0.40), reasonable (between 0.40 and 0.59), good (between 0.60 and 0.74), and excellent (between 0.75 and 1.00).

Analysis of the data collected from the questionnaires

The normality of the data was tested with the Kolmogorov-Smirnov test, and when nonnormal distribution was present, the data were log normalized before the parametric tests were performed. Descriptive statistics were found using the frequency, percentage, mean, and standard deviation for the scores and sociodemographic characteristics.

To evaluate the correlation between the scores obtained for KAP, the Pearson correlation test (r) was performed considering the strength of the correlations and respective probability of errors ( p  ≤ 5%). The strength of the correlations was classified as negligible (0.01 to 0.09), low (0.10 to 0.29), moderate (0.30 to 0.49), substantial (0.5 to 0.69) and strong (≥0.70), as suggested by Davis [ 23 ].

T-test and analysis of variance (ANOVA) were conducted, followed by Tukey’s test, to compare the means of the KAP score while considering sociodemographic variables. A multiple linear regression analysis was performed to identify the variables that impacted the KAP scores. The model for the multiple linear regression analysis was established to identify the impact of the explanatory variables (schooling, experience, participation in training, time since the previous training, knowledge and attitudes) on KAP scores. All analyses adopted a significance level of 5%.

Ethical aspects

The participants were informed about the study objectives and methodologies and signed the Free and Informed Consent Form if they agreed to participate in the study. The study was approved by the Ethics and Research Committee of the Federal University of Espírito Santo (UFES) in number 1.632.711.

Evaluation of the knowledge, attitudes and practices of food handlers

Questionnaire reproducibility.

The reproducibility and internal consistency analyses showed that the questionnaire applied in the present study falls within the range of accepted repeatability. The intraclass correlation coefficient was 0.64.

Application of the questionnaire

Sociodemographic characteristics of the food handlers.

The sociodemographic variables obtained from 172 food handlers via the questionnaire are shown in Table  1 . The majority (96.5%, n  = 166) of the participants were female, aged between 40 and 49 years (44.8%, n  = 78). Regarding education, most of the participants (57.9%, n  = 99) attended high school, and 40.7% ( n  = 70) attended only elementary school.

Most of the participants had up to 5 years of experience in the role (39.5%, n  = 68) and had participated in at least 4 training sessions (74.4%, n  = 128), the most recent of which had occurred within 3 months (52.0%, n  = 44).

KAP questionnaire performance

An evaluation of the results obtained through the KAP questionnaire found that the lowest scores were obtained on the knowledge assessment block (73.3%) (Table  2 ).

Boards 1, 2 and 3 present the results for the KAP questionnaire responses and their respective evaluation blocks (see Additional file 2 ). The questions that yielded a high percentage of correct responses in the knowledge-related block (Board 1) addressed the risk of food contamination from food handlers through disease, nonuse of good food-handling practices, and food defrosting and risk of disease due to the consumption of expired foods.

Question 1 on this topic (Board 1) had the highest proportion of incorrect answers (91.8%). Most of the participants stated that hand washing with soap is sufficient to avoid food contamination, which raises the question of whether the low number of correct answers was related to lack of knowledge (because they considered the use of detergent to be a correct practice) or was due to misinterpretation of the question.

In question 4 (Board 1), food handlers had the low number of correct answers (39%) may have been a consequence of doubt about the effects of the water phase change on microbiological risks.

Regarding the risks of using foods the day after their expiration date, addressed in question 7 (Board 1), 90.7% ( n  = 156) of the food handlers answered this question correctly. However, on question 6, only 25% ( n  = 43) of the participants reported that foods unfit for consumption always have a bad smell and a spoiled taste.

In contrast to the results for the knowledge block, the participants demonstrated good performance on the questions about attitudes (Board 2), especially question 10, to which all participants responded correctly. Only question 5 received less than 90% correct answers. A high percentage of correct responses (> 90%) was also observed by other authors [ 14 , 15 ].

Among the most frequent correct practices by food handlers (Board 3) was the use of cleansing solutions when washing vegetables and fruits (91.9%, n  = 158), addressed in question 6.

The correlation between the scores obtained for KAP was considered low (Table  3 ). Knowledge scores were not related to self-reported practices scores.

Table  4 presents the comparison of the mean scores obtained by the food handlers considering sociodemographic variables. The data indicate significant differences in knowledge scores according to the amount of experience in the role and the time since the most recent training. A significant difference in attitudes was observed according to schooling and the time since the most recent training. There was no significant difference in the scores obtained for practices.

The model for the multiple linear regression analysis was established to identify the impact of the explanatory variables (schooling, experience, participation in training, time of the previous training, knowledge and attitudes) on KAP scores. For this analysis, only the variables that presented statistically significant results were included in the bivariate analysis. To identify the association between the variables, the KAP score considered the assumption of the effect of knowledge on the change in attitudes and practices as well as the influence of attitudes on practices.

All the models presented significant results on the F-test, indicating good model fit, and results ranging from 1.5 to 2.5 on the Durbin Watson test of residual autocorrelation.

The linear regression analysis (Table  5 ) allowed us to identify that the knowledge score increased according to greater experience, but this increase was significant only for those who had spent up to 10 years in the role.

About questionnaire reproducibility, intraclass correlation coefficient was a good index of reproducibility according to Cicchetti [ 22 ]. Bas et al. [ 18 ], Nee and Sani [ 24 ], Halim et al. [ 25 ] and Mohd et al. [ 26 ] also tested the reliability of the questionnaires with food handlers and found good indexes of between 0.70 and 0.78.

Majority of food handler were female, aged between 40 and 49 years and attended high school. These results are similar to those found in other studies [ 15 , 19 , 27 , 28 ], which also observed a predominance of females in food services in schools. Food service sector is usually dominated by the female labor force. Although the inclusion of women in the labor market has been marked by several changes, reports still indicate that women predominantly work in fields associated with domestic employment, such as the preparation of food [ 29 , 30 ].

Regarding education, most of the participants (57.9%) attended high school, and 40.4% attended only elementary school. These levels of schooling are characteristic of the profile of these professionals, as shown in other Brazilian studies [ 15 , 19 ] and studies in other countries [ 27 ]. Brazilian legislation does not establish a specific schooling level for food handlers [ 3 ]; however, it requires that these professionals be subject to periodic training. Because this work does not require a high level of education and qualification, remuneration is low. This factor negatively affects the training and interventions performed in food services because it can influence the motivation of workers and consequently interfere with the adoption of appropriate attitudes and practices [ 31 , 32 ]. There is a linear relationship between food handlers’ educational level and the implementation of good practices in food services. Consequently, access to food handler’s education levels is important when planning training strategies. According Akabanda et al. [ 33 ], training can improve the food safety knowledge of food handlers, but this does not guarantee a positive adjustment in food handling behavior and attitudes.

Most of the food handlers of this study had up to 5 years of experience in the role and participated in at least 4 training. Cunha et al. [ 15 ], Soares et al. [ 19 ] and Vo et al. [ 34 ] also reported a high number of food handlers who underwent training, indicating good compliance with Brazilian legislation [ 3 ] regarding periodic training for food handlers. Hygiene training and education can be understood as a planned learning event intended to improve their knowledge about work-related activities; it can also be viewed as a source of perpetual changes in practices and attitudes [ 32 , 33 ]. It is a requirement in the food production environment and provides continuous improvement opportunities for food handlers. Instruction should be offered every 6–12 months and its efficacy must be evaluated. It is important to mentioned that food safety education need to be conducted with methods that encourage behavioral change and purchase practical abilities [ 35 ].

Results obtained through the KAP questionnaire indicated that the lowest scores were found on the knowledge block. A similar result was found in studies by Soares et al. [ 19 ] and Lee et al. [ 36 ], which verified that the participants’ level of knowledge was insufficient and moderate, respectively. It is important to highlight that within the food service environment, it is necessary to seek continuous improvement. These results point to the need for improvements in food handlers’ knowledge. The findings show that food handlers have adopted attitudes that helped produce safe food, but they provided incorrect answers to questions directly related to food quality control. According to Soares et al. [ 19 ], self-reported practices tend to be overstated by respondents, i.e., they responded what is probable rather than what they truly do within the food service environment. It is important to emphasize that the food handlers’ participation in this research and the fact that the questionnaire was self-applied may have influenced the large number of adequate answers.

Seven knowledge questions presented a high percentage of correct answers (Board 1). However, a question about hand hygiene has high percentage of incorrect answers. Highest proportion of food handlers stated that hand washing with soap is sufficient to avoid food contamination. According to Brazilian legislation, hand sanitation should be performed with an antiseptic and odorless liquid soap or an odorless liquid soap and an antiseptic product [ 3 ]. Incorrect knowledge and interpretation of food handling practices could lead to lower awareness of good handling procedures and false ideas about food safety [ 16 ]. It is important to mention that the question about hand washing may have been misunderstood by food handlers. The lack of hand hygiene is a critical aspect. Food handlers’ hands can be as vectors in the spread of foodborne diseases due to inadequate individual hygiene or cross contamination behavior [ 37 , 38 , 39 ].

Although the subject of hand hygiene is constantly addressed with food handlers, this does not guarantee that will perform the procedure correctly and then can be a source of contamination. This fact can be justified by the food handlers’ low perception of the risks associated with incorrect practices or by work overload that causes employees to prioritize other activities that are considered more relevant [ 15 ]. Adopting correct hand hygiene practices is essential because failures of personal hygiene can cause food handlers to become sources of pathogenic microorganisms and cross-contamination [ 18 ]. Appropriate hand washing practices by food handlers can significantly decrease the risk of diarrheal disease and other foodborne diseases [ 33 ].

Another question with incorrect answers was related to the quality of water. According to legislation, ice for use in food must be made from drinking water and maintained in hygienic and sanitary conditions to prevent contamination [ 3 ]. Although the use of ice was been observed in the visited SFS, it is imperative that the entire food safety concept is conveyed to food handlers. Water supply is a relevant aspect, since is one of the main causes of foodborne diseases outbreaks in Brazil.

Food handlers reported that contaminated food always have a bad smell and a spoiled taste. This finding represents a relevant problem because it indicates that the food handlers do not perceive the risks associated with using contaminated foods. This result similar to those of Soares et al. [ 19 ] in a study of 166 food handlers in public schools in Camaçari, Bahia, in which only 16.3% of the participants were aware that contaminated food does not necessarily show changes in color, odor or taste. A different result was obtained by Walker et al. [ 35 ], in which 57% of the participants stated that they would know if the food were contaminated via sensory verification.

About attitudes, food handlers presented a better result than knowledge block (Board 2). A high percentage of correct responses for attitudes (> 90%) was also observed by other authors [ 14 , 15 ]. According Akabanda et al. [ 33 ], the food handlers’ attitudes can influence the occurrence of foodborne diseases. Thus, they need to follow the food safety plans. However, it is important to declare that the attitudes were self-reported. Thus, there is a possibility that the participants answered something that in their day-to-day lives they do not effectively accomplish.

Practices evaluation about washing food was considerably higher than that obtained by Soares et al. [ 19 ]. These authors found that 48.2% of the participants conducted incorrectly sanitization procedure because the great majority did not have a consistent supply of cleanser in the SFS. The attitudes of food handlers are known to be important in the application of knowledge and can have a significant impact on individuals’ behavior and practices [ 36 ]. The inadequate of knowledge level can culminate to poor hygienic practices by food handlers [ 33 ]. However, food handlers’ reported practices may not be essentially coherent with procedures performed during food handling. Inspiration and motivation during hygiene training and education could be a strategy to positively affect attitudes and practices and conduct to an appropriate behavior on kitchens. It is important to mentioned that food handlers may have an over-report of good performances contrasted to their usual practices when not asked or observed.

In this study, knowledge scores were not correlated to self-reported practices scores. This corroborating the results obtained in studies by Cunha et al. [ 15 ] and Park, Kwak & Chang [ 40 ]. However, contradictory results are described by Rahman et al. [ 41 ] and Vo et al. [ 34 ]. Rebouças et al. [ 42 ] did not observe a significant association between knowledge, attitudes and self-reported practices among food handlers, head chefs and managers in hotel restaurants in Salvador, Brazil. The low correlation between knowledge and attitude scores shows that the food handlers’ knowledge about food safety can influence their food handling attitudes. In other words, food handlers with low knowledge levels may have inappropriate attitudes.

Another point observed in this study was a significant difference in knowledge scores according to the amount of experience in the role and the time since the most recent training. A significant difference in attitudes was observed according to schooling and the time since the most recent training. There was no significant difference in the scores obtained for practices. Nee and Sani [ 24 ] observed that food handlers with less than one year of experience had lower scores for knowledge than those who had more than 6 years of experience. In addition, as the time since the previous training increased, the knowledge score decreased, becoming statistically significant when the training had been conducted more than 1 year previously. Cunha et al. [ 15 ] found a difference in knowledge scores between recently trained food handlers and those with a longer time interval since training (18, 24, 36 months), suggesting a possible recommendation of biannual training with a maximum interval of one year to maintain the food handlers’ working knowledge.

The results of this study also indicated that an increase in the level of schooling was associated with an increase attitude score. The results differ from those of other authors, who did not show a significant relationship between level of schooling and attitudes but did find a relationship between schooling and the knowledge and practices of food handlers [ 19 , 35 ]. The reduction in the attitudes score was more significant among those who had undergone retraining in the previous 6 months. This result may have been influenced by the self-reported nature of these responses because the attitudes score was higher among those who had undergone training more recently (in the previous 3 months).

Given the results presented, suitable solutions are necessary. These results can contribute to future research as well as to the planning of training and guidance about food safety. Food handlers must receive information to apply it to their work routine.

The present study was subject to limitations, such as the impossibility of visiting all schools in the municipality and reliance on the answers of the participants. The food handlers may have answered some questions correctly, which may or may not truly reflect what they do on a daily basis. To get closer to the reality of food handlers’ practices, it would be necessary to observe their entire daily work routine. In addition, it is known that the presence of a researcher in the work environment may influence participants’ responses to a questionnaire.

The results obtained in this study indicated that, although the level of knowledge of the participants in general was sufficient, it was inferior when compared to scores on the comprehension of attitudes and practices of the food handlers on certain concepts related to food safety. The association of the KAP score with the sociodemographic variables indicates the need for training programmes on good practices to consider these factors. In addition, the specifics (themes, difficulties, motivation) in the effectiveness of the program’s impact on knowledge acquisition must be taken into account but are mainly important in changing the attitudes, practices and understanding of the food handlers regarding their role in school food preparation.

In this context, the adoption of evaluative methods before and after training to identify the aspects to be improved and the relevance of the training programme for food handlers is suggested. An intervention strategy with the involvement of all social actors of National School Feeding Program is essential, given the importance of the program, the appropriate responsibilities within it and in view of the irregularities observed. Consequently, the results of improvements will be more effective. We recommended a training schedule for food handlers to guarantee their continued training in food safety. In addition, the professional nutritionists, who are responsible for monitoring this food service, should regularly supervise the routine of school kitchens. Intervention activities aimed at food safety must be constant and monitored, even during the work routine, so that, from the moment of identifying the failures, corrective actions occur immediately. Thus, in order to not only indicate the food handlers about the mistake, but also to guide him on why and the importance of correcting certain incorrect behavior.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Foodborne diseases

National School Feeding Program

School Food Service

Municipal Secretary of Education

Centers for Early Childhood Education

Municipal Schools of Elementary Education

Knowledge, attitudes and practices

World Health Organization (WHO). Food safety. Geneva, Switzerland; 2015. http://www.who.int/mediacentre/factsheets/fs399/en/ . Accessed Dec 2015.

Google Scholar  

Ministério da Saúde (MS). Surtos de Doenças Transmitidas por Alimentos no Brasil. Secretaria de Vigilância em Saúde. Brasil, 2016. http://portalarquivos.saude.gov.br/images/pdf/2016/dezembro/09/Apresentacao-Surtos-DTA-2016.pdf . Accessed Feb 2017.

Brasil. Resolução RDC n° 216 de 15 de setembro de 2004. Dispõe sobre Regulamento Técnico de Boas Práticas para Serviços de Alimentação. Diário Oficial da República Federativa do Brasil, 2004.

Fundo Nacional de Desenvolvimento da Educação (FNDE). Alimentação escolar. Brasil, 2015. http://www.fnde.gov.br/programas/alimentacao-escolar . Accessed Nov 2015.

São José JFB. Contaminação microbiológica em serviços de alimentação. Nutrire. 2012;37:78–92.

Article   Google Scholar  

Leite CL, Cardoso RCV, Góes JAW, Figueiredo KVNA, Silva EO, Bezerril MM, Júnior POV, Santana AAC. Formação para merendeiras: uma proposta metodológica aplicada em escolas estaduais atendidas pelo programa nacional de alimentação escolar, em Salvador, Bahia. Rev Nutr. 2011;24:275–85. https://doi.org/10.1590/S1415-52732011000200008 .

Cunha DT, Stedefeldt E, Rosso VV. Perceived risk of foodborne disease by school food handlers and principals: the influence of frequent training. J Food Saf. 2012;32:219–25. https://doi.org/10.1111/j.1745-4565.2012.00371.x .

Centers of Disease Control and Prevention (CDC). Surveillance for Foodborne-Disease Outbreaks — United States, 1988–1992. Morbidity and mortality weekly report. CDC Surveillance Summaries, vol. 45; 1996. p. 1–73. http://www.cdc.gov/mmwr/pdf/ss/ss4505.pdf . Accessed Nov 2015

Food and Drug Administration (FDA). FDA Report on the Occurrence of Foodborne Illness Risk Factors in Selected Institutional Foodservice, Restaurant, and Retail Food Store Facility Types (2009). FDA National Retail Food Team, 2009.

Gomes NAAA, Campos MRH, Monego ET. Aspectos higiênico-sanitários no processo produtivo dos alimentos em escolas públicas do Estado de Goiás, Brasil. Rev Nutr. 2012;25:473–85. https://doi.org/10.1590/S1415-52732012000400005 .

Lopes ACC, Pinto HRF, Costa DCIO, Mascarenhas RJ, Aquino JS. Avaliação das Boas Práticas em unidades de alimentação e nutrição de escolas públicas do município de Bayeux, PB, Brasil. Ciênc saúde coletiva. 2015;20:2267–75. https://doi.org/10.1590/1413-81232015207.15162014 .

Cunha DT, Fiorotti RM, Baldasso JG, Sousa M, Fontanezi NM, Caivano S, Stedefeldt E, Rosso VV, Camargo MCR. Improvement of food safety in school meal service during a long-term intervention period: a strategy based on the knowledge, attitude and practice triad. Food Control. 2013;34:662–7. https://doi.org/10.1016/j.foodcont.2013.06.003 .

Garcia PPC. A eficácia do treinamento de manipuladores de alimentos: o modelo transteórico em foco. Dissertação de mestrado: Universidade de Brasília, Brasília; 2013.

Ansari-Lari M, Soodbakhsh S, Lakzadeh L. Knowledge, attitudes and practices of workers on food hygienic practices in meat processing plants in Fars. Iran Food Control. 2010;21:260–3. https://doi.org/10.1016/j.foodcont.2009.06.003 .

Cunha DT, Stedefeldt E, Rosso VV. The role of theoretical food safety training on brazilian food handlers’ knowledge, attitude and practice. Food Control. 2014;43:167–74. https://doi.org/10.1016/j.foodcont.2014.03.012 .

Sani NA, Siow ON. Knowledge, attitudes and practices of food handlers on food safety in food service operations at the Universiti Kebangsaan Malaysia. Food Control. 2014;37:210–7. https://doi.org/10.1016/j.foodcont.2013.09.036 .

Moreira AD. Validade e reprodutibilidade de questionário de atividade física do sistema de vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Dissertação de mestrado: Universidade Federal de Minas Gerais, Belo Horizonte; 2013.

Bas M, Ersun AS, Kivanç G. The evaluation of food hygiene knowledge, attitudes, and practices of food handlers in food businesses in Turkey. Food Control. 2006;17:317–22. https://doi.org/10.1016/j.foodcont.2004.11.006 .

Soares LS, Almeida RCC, Cerqueira ES, Carvalho JS, Nunes IL. Knowledge, attitudes and practices in food safety and the presence of coagulase positive staphylococci on hands of food handlers in the schools of Camaçari. Brazil Food Control. 2012;21:206–13. https://doi.org/10.1016/j.foodcont.2012.03.016 .

Food and Agriculture Organization of the United Nations (FAO). Codex Alimentarius. Recommended international code of practice general principles of food hygiene. In: CAC/RCP 1–1969 (Ed.), (Rev. 4 ed.); 2003.

World Health Organization (WHO). Five keys to safer food. Geneva, Switzerland; 2006. http://www.who.int/foodsafety/publications/consumer/5keys/en/ . Accessed DEC 2015.

Cicchetti DV. Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychol Assess. 1994;6:284–90. https://doi.org/10.1037/1040-3590.6.4.284 .

Davis JA. Levantamentos de dados em sociologia: uma análise estatística elementar. Zahar: Rio de Janeiro; 1976. p. 239.

Nee SO, Sani NA. Assessment of knowledge, attitudes and practices (KAP) among food handlers at residential colleges and canteen regarding food safety. Sains Malaysiana. 2011;40:403–10.

Halim MHAA, Nagaretnam L, Azman SAN, Saliluddin SM, Mahmud A. Association between knowledge, attitude, practice (KAP) and hygiene status of food handlers and premises in cafeterias of a public University in Malaysia. Int J Public Health Clin Sci. 2014;1:181–8.

Mohd FSA, Son R, Mohhiddin O, Toh PS, Chai LC. Food court hygiene assessment and food safety knowledge, attitudes and practices of food handlers in Putrajaya. IFRJ. 2015;22:1843–54.

Sibanyoni JJ, Tshabalala PA, Tabit FT. Food safety knowledge and awareness of food handlers in school feeding programmes in Mpumalanga, South Africa. Food Control. 2016;73:1397–406. https://doi.org/10.1016/j.foodcont.2016.11.001 .

Tan SL, Bakar FA, Karim MSA, Lee HY, Mahyudin NA. Hand hygiene knowledge, attitudes and practices among food handlers at primary schools in Hulu Langat district, Selangor (Malaysia). Food Control. 2013;34:428–35. https://doi.org/10.1016/j.foodcont.2013.04.045 .

Ferreira JS, Carvalho JS, Cerqueira ES, Oliveira LC, Costa WLR, Almeida RCC. Conhecimento, atitudes e práticas em segurança alimentar de manipuladores de alimentos em hospitais públicos de Salvador, Bahia. Revista Baiana de Saúde Pública. 2013;37:35–55.

Bruschini MCA. Trabalho e gênero no Brasil nos últimos dez anos. Cad Pesqui. 2007;37:537–72.

Seaman P, Eves A. The management of food safety - the role of food hygiene training in the UK service sector. Int J Hosp Manag. 2006;25(2):278–96. https://doi.org/10.1016/j.ijhm.2005.04.004 .

Seaman P. Food hygiene training: introducing the food hygiene training model. Food Control. 2010;21(4):381–7. https://doi.org/10.1016/j.foodcont.2009.08.005 .

Akabanda F, Hlortsi EH, Owusu-kwarteng J. Food safety knowledge, attitudes and practices of institutional food-handlers in Ghana. BMC Public Health, 2017:1–9. https://doi.org/10.1186/s12889-016-3986-9 .

Vo TH, Le NH, Le ATN, Minh NNT, Nuorti JP. Knowledge, attitudes, practices and training needs of food-handlers in large canteens in southern Vietnam. Food Control. 2015;57:190–4. https://doi.org/10.1016/j.foodcont.2015.03.042 .

Cunha, D. T., de Rosso, V. V., Pereira, M. B., & Stedefeldt, E. The differences between observed and self-reported food safety practices: A study with food handlers using structural equation modelling. Food Res Int, 2019; 125, https :// https://doi.org/10.1016/j.foodres.2019.108637 .

Lee HK, Halim HA, Thong KL, Chai LC. Assessment of food safety knowledge, attitude, self-reported practices, and microbiological hand hygiene of food handlers. Int. J. of environ. Res. Public Health. 2017;14(55):1–14. https://doi.org/10.3390/ijerph14010055 .

Samapundo S, Cam Thanh TN, Xhaferi R, Devlieghere F. Food safety knowledge, attitudes and practices of street food vendors and consumers in ho chi Minh city, Vietnam. Food Control. 2016;70:79–89. https://doi.org/10.1016/j.foodcont.2016.05.037 .

Walker E, Pritchard C, Forsythe S. Food handlers’ hygiene knowledge in small food businesses. Food Control. 2003;14:339–43. https://doi.org/10.1016/S0956-7135(02)00101-9 .

Ovca A, Jevsnik M, Kavci M, Raspor P. Food safety knowledge and attitudes among future professional food handlers. Food Control. 2018;84:345–53. https://doi.org/10.1016/j.foodcont.2017.08.011 .

Park SH, Kwak TK, Chang HJ. Evaluation of the food safety for food handlers in restaurant operations. Nutr Res Pract. 2010;4(1):58–68. https://doi.org/10.4162/nrp.2010.4.1.58 .

Article   PubMed   PubMed Central   Google Scholar  

Rahman M, Arif MT, Bakar K, Tambi Z. Food safety knowledge, attitude and hygiene practices among the street food vendors in northern Kuching city, Sarawak. Borneo Sci. 2012;31:95–103.

Rebouças LT, Santiago LB, Martins LS, Menezes ACR, Araújo MPN, RCC A. Food safety knowledge and practices of food handlers, head chefs and managers in hotels' restaurants of Salvador, Brazil. Food Control. 2017;73(Part B):372–81. https://doi.org/10.1016/j.foodcont.2016.08.026 .

Download references

Acknowledgements

The authors gratefully acknowledge the Foundation for the Support of Research and Innovation of Espírito Santo ( Fundação de Amparo a Pesquisa e Inovação do Espírito Santo- FAPES ) for the scholarship grant for the first author. We thank Coordination for the Improvement of Higher Education Personnel ( Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES) for support to the Graduate Program in Nutrition and Health of Universidade Federal do Espírito Santo. We thank Secretaria Municipal de Educação de Vitória-ES for the authorization to execute the project. We thank Pro-Reitoria de Extensão of Universidade Federal do Espírito Santo for all their support.

Foundation for the Support of Research and Innovation of Espírito Santo ( Fundação de Amparo a Pesquisa e Inovação do Espírito Santo- FAPES ) for the scholarship grant for the first author.

Author information

Authors and affiliations.

Student of Nutrition and Health Postgraduate Program, Federal University of Espírito Santo, Avenida Marechal Campos, 1468, Vitória, 29040-090, Brazil

Alyne Gomes da Vitória & Jhenifer de Souza Couto Oliveira

Department of Integrated Education in Health, Federal University of Espírito Santo, Avenida Marechal Campos, 1468, Vitória, 29040-090, Brazil

Louise Caroline de Almeida Pereira

Nutrition and Health Postgraduate Program, Federal University of Espírito Santo, CEP 29043-910, Marechal Campos, 1468, Vitória, 29040-090, Brazil

Carolina Perim de Faria & Jackline Freitas Brilhante de São José

You can also search for this author in PubMed   Google Scholar

Contributions

AGV, and JFBSJ conceived the study and its original design, drafted the initial form and all revisions of this paper. AGV, JSCO and LCAP collected the data. AGV and CPF analyzed the data. AGV, JSCO, LCAP, CPF and JFBSJ reviewed and approved the final manuscript.

Corresponding author

Correspondence to Jackline Freitas Brilhante de São José .

Ethics declarations

Ethics approval and consent to participate.

The study was approved by the Ethics and Research Committee of the Federal University of Espírito Santo (UFES), in number 1.632.711. The participants were informed about the study objectives and methodologies and signed the Free and Informed Consent Form if they agreed to participate in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1..

Questionnaire: Evaluation of Knowledge, Attitudes and Practices of Food Handlers.

Additional file 2. Board 1

Knowledge of food safety by food handlers from 52 schools in in Vitória, Espírito Santo, Brazil. Board 2 Evaluation of food safety attitudes by food handlers from 52 schools in Vitória, Espírito Santo, Brazil. Board 3 Evaluation of food safety practices by food handlers from 52 schools in Vitória, Espírito Santo, Brazil.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

da Vitória, A.G., de Souza Couto Oliveira, J., de Almeida Pereira, L.C. et al. Food safety knowledge, attitudes and practices of food handlers: A cross-sectional study in school kitchens in Espírito Santo, Brazil. BMC Public Health 21 , 349 (2021). https://doi.org/10.1186/s12889-021-10282-1

Download citation

Received : 13 July 2020

Accepted : 20 January 2021

Published : 12 February 2021

DOI : https://doi.org/10.1186/s12889-021-10282-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Food safety
• Food handling
• Food hygiene
• School feeding
• Food service
• Collective feeding
• Food quality

BMC Public Health

ISSN: 1471-2458

• Submission enquiries: [email protected]
• General enquiries: [email protected]

• Research note
• Open access
• Published: 22 October 2019

Factors associated with food safety practices among food handlers: facility-based cross-sectional study

• Jember Azanaw 1 ,
• Mulat Gebrehiwot 1 &
• Henok Dagne 1  

BMC Research Notes volume  12 , Article number:  683 ( 2019 ) Cite this article

75k Accesses

42 Citations

Metrics details

The primary objective of this study was to assess factors associated with food safety practices among food handlers in Gondar city food and drinking establishments. The facility-based cross-sectional study was undertaken from March 3 to May 28, 2018, in Gondar city. Simple random sampling method was used to select both establishments and the food handlers. The data were collected through face-to-face interview using pre-tested Amharic version of the questionnaire. Data were entered and coded into Epi info version 7.0.0 and exported to SPSS version 22 for analysis.

One hundred and eighty-eight (49.0%) had good food handling practice out of three hundred and eighty-four food handlers. Marital status (AOR: 0.36, 95% CI 0.05, 0.85), safety training (AOR: 4.01, 95% CI 2.71, 9.77), supervision by health professionals (AOR: 4.10, 95% CI 1.71, 9.77), routine medical checkup (AOR: 8.80, 95% CI 5.04, 15.36), and mean knowledge (AOR: 2.92, 95% CI 1.38, 4.12) were the factors significantly associated with food handling practices. The owners, managers and local health professionals should work on food safety practices improvement.

Introduction

Food safety continues as a critical problem in developed and developing nations for people, food companies and food control officials [ 1 , 2 ]. Food-borne diseases (FBD) are associated with outbreaks and threatens global public health security and has got an international concern [ 3 ]. Food safety is a growing public health issue [ 4 ]. FBD is responsible for significant morbidity and mortality rates [ 5 ]. The worldwide incidence and financial expenses of food-borne diseases are hard to determine [ 6 ]. However, reports estimate that 2.1 million individuals died each year as a result of foodborne disease [ 5 ].

According to the WHO, FBDs in developing nations are serious because of bad hygienic food handling methods, bad understanding and absence of infrastructure [ 7 ]. This is due to the prevailing poor food handling and sanitation practices, inadequate food safety laws, weak regulatory systems, lack of financial resources, etc. [ 6 , 8 ]. Evidence revealed that around 70% of diarrhoea cases were attributed to food-borne routes in developing countries [ 6 ]. Like other developing countries, the burden of food-borne diseases is growing in Ethiopia [ 18 ].

Approximately 10 to 20% of FBD outbreaks are because of contamination due to poor food handling practice of the food handlers [ 9 ]. In the absence of well-maintained and proper food handling practices in mass catering establishments have the potential to impart a disastrous effect on human health [ 6 , 11 ].

Good personal hygiene and food handling practices are important for preventing the transmission of pathogens from food handlers to the consumers [ 12 , 13 , 14 ]. Close to 75% of food-borne illness outbreaks are attributed to lack of safe food handling practices by food handlers in food service establishments [ 5 ]. Food handlers play a key role in ensuring strict adherence to food safety principles throughout the whole process [ 15 ].

There is a high expansion of food establishments observed in the country including Gondar city. But ensuring safe food service has been one of the major challenges and concerns for producers, consumers and public health officials. Studies revealed that lack of basic sanitary facilities/infrastructures, poor knowledge and practice of hygiene and sanitation among food handlers in food service establishments, and negligence in safe food handling are major reasons of poor food safety practice in food establishments [ 16 , 17 ]. Therefore, it is very essential to identify factors affecting safe food handling practices, especially during preparation and serving. Thus, this study aimed to evaluate factors associated with food safety practice among food handlers in Gondar city food establishments.

This facility-based cross-sectional study was conducted from March 3 to May 28, 2018 at Gondar city. Gondar city is one of the highly populated cities in northwest Ethiopia. There were a total of 326 food establishments and 4232 food handlers in Gondar city according to tourism office data. The city is found at 738 km away from Addis Ababa the capital city of Ethiopia. Ninety-eight food establishments were included using the rule of thumb by taking 30% of the total food establishments. n = N × 30% = 326 × 30/100 = 97.8 ≈ 98 none star food establishments.

The sample size was computed using a single population proportion formula with 95% CI, 5% marginal error (d) and p = 52% proportion of food handlers having good food handling practice from the previous study [ 19 ]. Based on these assumptions, 384 food handlers were included in the study.

To select food establishments and food handlers, a simple random sampling technique was used. In each institution, four food handlers were interviewed. After adaptation from similar literature [ 12 , 19 , 20 , 21 ], the questionnaire was first prepared in English and translated to local language Amharic version. The pre-test was performed on 5% food handlers out of the study area before actual data collection. Then, correction and modification were undertaken based on the gaps identified during the pre-test. Reliability of the questionnaire was also evaluated. The information was gathered via a face-to-face interview using the questionnaire’s Amharic version. Four Environmental Health Officers have been engaged as data collectors and the principal investigator was involved as a supervisor. Food safety practice was the dependent variable in this research. Socio-demographic variables and behavioural factors were the independent variables. Food handling practice: food handlers were asked seventeen questions and those who scored less than or equal to the mean value were considered as having poor practice and those who scored greater than the mean value were considered as having good practice [ 19 , 21 ]. Knowledge: Respondents were asked ten questions and those who scored less than or equal to the mean value were considered as having a poor knowledge [ 12 , 22 ].

Consistency and completeness of data were verified during collection, entry and analysis. Data were entered and coded into version 7.0.0 of Epi Info and exported for evaluation to version 22 of SPSS. The data were analysed using descriptive (frequency and proportion), bivariate, and multivariable regression analysis. Variables with p-value < 0.25 during bivariate analysis were included in multivariable regression to assess the independent effect after controlling other variables [ 23 ].

We did Hosmer and Lemeshow test to check the model fitness. SPSS Cronbach’s Alpha test result for practice questionnaire was 0.83. Finally, 95% confidence level, AOR and p-value less than 0.05 were considered for determining statistically significant variables.

Sociodemographic characteristics of study participants

Of the three hundred eighty-four food handlers, 338 (88%) were females, 300 (78.1%) were unmarried; and 318 (82.8%) had an income of 500–1000 Ethiopian birr (28 ETB = 1 USD) (Table  1 ).

Knowledge of food handlers regarding the cause of food-borne disease, mode of transmission and way of food contamination

Three hundred sixteen (82.29%) of food handlers stated that food-borne diseases are caused by germs. More than half 199 (51.8%) of food handlers found this information from health center about food safety practices (Table  2 ).

Food handling practice of food handlers in food and drinking establishments

More than half of (51.5%) food handlers use hair net during food preparation. One hundred ninety (49.5%) of food handlers did not attend routine medical checkups. About 37% of the respondents were not wearing a uniform during handling and preparation of food (Table  3 ).

Factors associated with food safety practices

Multivariable logistic regression analysis revealed that marital status, food safety training, routine medical checkup, supervision by health professionals and knowledge were statistically associated variables with food safety practices.

Single food handlers were 64.0% less likely to practice food safety than the single food handlers (AOR: 0.36, 95% CI 0.05, 0.85). Food handlers supervised by health professionals were 4.10 times more likely to practice good food safety than non-supervised (AOR: 4.10, 95% CI 1.71, 5.27). Knowledgeable food handlers were 2.92 times more likely to practices good food safety than non-knowledgeable (AOR: 2.92, 95% CI 1.38, 4.12). Trained food handers were 4.01 times more likely to have good food handling practice than non-trained food handlers (AOR: 4.01, 95% CI 2.71, 9.77). Food handers followed routine medical checkup had 8.80 times more likely to have good food handling practice than not- followed food handlers (AOR: 8.80, 95% CI 5.04, 15.36) (Table  3 ).

One hundred eighty-eight (49.0%) food handlers had good food safety practice. This finding is lower than the findings of studies in Bahir Dar (67.6%) [ 24 ], Arba Minch (67.4%) [ 21 ] and in Dubai (81.74%) [ 17 ]. While the finding was close with studies in Dangila town (52.5%), Addis Ababa (52.3%), Imo State, Nigeria (50%) and Turkey (48.4%) [ 6 , 19 , 25 , 26 ], respectively. However, it is higher than the studies done in Gondar town (22.1%) [ 5 ], South-Western Nigeria (19.0%) [ 27 ], Ogun, Nigeria (31.5%) [ 19 ]. These variations might be due to the difference in the study design, variation in training, and the provision of food hygiene and safety inputs. About 109 (28.4%) of the food handlers were certified in food safety training. This result is higher as compared with findings from Bahir Dar (21.8%) and Mekelle (15.7%) [ 12 , 28 ]. Food handler training is seen as one strategy whereby food safety practice can be increased, offering long-term benefits to the food establishments [ 29 ]. This finding is supported with studies conducted India [ 10 ], Nigeria [ 30 ], Ghana [ 31 ] and Dubai [ 32 ]. The number of food handlers who recieved food safety training in the current study is higher than with findings from Bahir Dar (21.8%), and Mekelle (5.4%) [ 12 , 28 ]. Food handlers who received training would have a better understanding of safe food handling practice as they might get professional advice during training. Training could enhance food handlers overall performance in safe food handling practice [ 21 ]. In this study, food handlers who got safety training had higher odds of good food safety practice. This might be due to trained food handlers gain good awareness through training. This supported with other similar study done in Sarawak [ 33 ]. Training programs are important for improving the knowledge of food handlers [ 34 ]. Food safety practice was also positively associated with the level of knowledge. The probability of having a good food safety practice among participants with good level of knowledge was 2.39 times higher with compared to those with a poor level knowledge (AOR = 2.39, 95% CI 1.38, 4.12). Food handlers are expected to have substantial knowledge and skills for handling foods hygienically [ 12 ]. This might be due to those food handlers who had a good level knowledge might have a higher chance of good food handling practice. This finding was supported studies conducted in Gondar town, and Malaysia [ 5 , 15 ]. Marital status was another significantly associated factor with food safety practices. Single food handlers had lower probability of good food safety practices compared with divorced handlers. This is supported with the study done in Gondar town and Dangila town [ 19 ].

Food safety practice was significantly associated with supervision by health professionals. The probability of having good food safety practice was higher among food handlers supervised by health professionals as compared with non-supervised. This finding was supported by the study conducted in Arba Minch [ 21 ]. This might be due to supervisors give advice for food handlers, the owners and to the managers. A routine medical checkup was also another factor significantly associated with good food handling practice. The probability of having good food safety practice among food handlers engaged with routine medical checkup was higher than food handlers not engaged in routine medical checkup. This could be the health care workers gave advice for food handlers during examination. This finding is in line with studies conducted in Arba Minch and Dessie towns [ 20 , 21 ]. This study revealed that there was poor food handling practice among food handlers. Marital status, food safety training, supervision by health professionals, routine medical checkup, and level of knowledge of food handlers were significantly associated with good food handling practice. Owners, managers and local health professionals should enhance the level of knowledge of food handlers, provide food hygiene, safety training, undertake periodic supervision, and routine medical checkup.

Limitations

This study was not without limitations. Some of the limitations include inherent weakness of cross-sectional study to establish a cause–effect relationship, social desirability bias and recall bias.

Availability of data and materials

We will make data available upon request the primary author.

Abbreviations

World Health Organization

adjusted odds ratio

confidence interval

crude odds ratio

Statistical Package for Social Sciences

Ethiopian Birr

Institutional Review Board

Osaili TM, Al-Nabulsi AA, Krasneh HDA. Food safety knowledge among food service staff at the universities in Jordan. Food Control. 2018;89:167–76.

Article   Google Scholar  

Smigic N, Djekic I, Martins ML, Rocha A, Sidiropoulou N, Kalogianni EP. The level of food safety knowledge in food establishments in three European countries. Food Control. 2016;63:187–94.

Adesokan HK, Akinseye VO, Adesokan GA. Food safety training is associated with improved knowledge and behaviours among foodservice establishments’ workers. Int J Food Sci. 2015;2015:328761.

Osimani A, Aquilanti L, Tavoletti S, Clementi F. Evaluation of the HACCP system in a university canteen: microbiological monitoring and internal auditing as verification tools. Int J Environ Res Public Health. 2013;10(4):1572–85.

Gizaw Z, Gebrehiwot M, Teka Z. Food safety practice and associated factors of food handlers working in substandard food establishments in Gondar Town, Northwest Ethiopia, 2013/14. Int J Food Sci Nutr Diet. 2014;3(7):138–46.

Google Scholar  

Meleko A, Henok A, Tefera W, Lamaro T. Assessment of the sanitary conditions of catering establishments and food safety knowledge and practices of food handlers in Addis Ababa University Students’ Cafeteria. Science. 2015;3(5):733–43.

Fasanmi O, Makinde G, Popoola M, Fasina O, Matere J, Ogundare S. Potential risk factors associated with carcass contamination in slaughterhouse operations and hygiene in Oyo state, Nigeria. Int J Livestock Prod. 2018;9(8):211–20.

World Health Organization. WHO estimates of the global burden of foodborne diseases: foodborne disease burden epidemiology reference grou. Geneva: World Health Organization; 2015. p. 2007–15.

Girma G. Prevalence, Antibiogram and Growth Potential of Salmonella and Shigella in Ethiopia: implications for Public Health: a Review. Res J Microbiol. 2015;10(7):288.

Article   CAS   Google Scholar  

Ali AI, Immanuel G. Assessment of hygienic practices and microbiological quality of food in an institutional food service establishment. J Food Process Technol. 2017;8:8.

Manes MR, Liu LC, Dworkin MS. Baseline knowledge survey of restaurant food handlers in suburban Chicago: do restaurant food handlers know what they need to know to keep consumers safe? J Environ Health. 2013;76(1):18–27.

PubMed   Google Scholar  

Kibret M, Abera B. The sanitary conditions of food service establishments and food safety knowledge and practices of food handlers in Bahir Dar town. Ethiop J Health Sci. 2012;22(1):27–35.

PubMed   PubMed Central   Google Scholar  

Al-Shabib NA, Mosilhey SH, Husain FM. Cross-sectional study on food safety knowledge, attitude and practices of male food handlers employed in restaurants of King Saud University, Saudi Arabia. Food Control. 2016;59:212–7.

Wambui J, Karuri E, Lamuka P, Matofari J. Good hygiene practices among meat handlers in small and medium enterprise slaughterhouses in Kenya. Food Control. 2017;81:34–9.

Asmawi UMM, Norehan AA, Salikin K, Rosdi NAS, Munir NATA, Basri NBM. An assessment of knowledge, attitudes and practices in food safety among food handlers engaged in food courts. Curr Res Nutr Food Sci J. 2018;6(2):346–53.

Okonko I, Adejoye O, Ogun A, Ogunjobi A, Nkang A, Adebayo-Tayo B. Hazards analysis critical control points (HACCP) and microbiology qualities of sea-foods as affected by handler’s hygience in Ibadan and Lagos, Nigeria. Afr J Food Sci (ACFS). 2009;3(2):35–50.

Kumie A, Mezene A, Amsalu A, Tizazu A, Bikila B. The sanitary condition of food and drink establishment in Awash-Sebat Kilo town, Afar Region, Ethiopia. Ethiop J Health Develop. 2006;20:3.

Mendedo EK, Berhane Y, Haile BT. Factors associated with sanitary conditions of food and drinking establishments in Addis Ababa, Ethiopia: cross-sectional study. Pan Afr Med J. 2017;28(1):237.

Tessema AG, Gelaye KA, Chercos DH. Factors affecting food handling Practices among food handlers of Dangila town food and drink establishments, North West Ethiopia. BMC Public Health. 2014;14(1):571.

Adane M, Teka B, Gismu Y, Halefom G, Ademe M. Food hygiene and safety measures among food handlers in street food shops and food establishments of Dessie town, Ethiopia: a community-based cross-sectional study. PLoS ONE. 2018;13(5):e0196919.

Legesse D, Tilahun M, Agedew E, Haftu D. Food handling practices and associated factors among food handlers in arba minch town public food establishments in Gamo Gofa Zone, Southern Ethiopia. Epidemiology (Sunnyvale). 2017;7(302):2161–5.

Nee SO, Sani NA. Assessment of knowledge, attitudes and practices (KAP) among food handlers at residential colleges and canteen regarding food safety. Sains Malaysiana. 2011;40(4):403–10.

Mickey RM, Greenland S. The impact of confounder selection criteria on effect estimation. Am J Epidemiol. 1989;129(1):125–37.

Derso T, Tariku A, Ambaw F, Alemenhew M, Biks GA, Nega A. Socio-demographic factors and availability of piped fountains affect food hygiene practice of food handlers in Bahir Dar Town, northwest Ethiopia: a cross-sectional study. BMC Res Notes. 2017;10(1):628.

Iwu AC, Uwakwe KA, Duru CB, Diwe KC, Chineke HN, Merenu IA, et al. Knowledge, attitude and practices of food hygiene among food vendors in Owerri, Imo State, Nigeria. J Occup Environ Med. 2017;5:11–25.

Baş M, Ersun AŞ, Kıvanç G. The evaluation of food hygiene knowledge, attitudes, and practices of food handlers’ in food businesses in Turkey. Food Control. 2006;17(4):317–22.

Faremi FA, Olatubi MI, Nnabuife GC. Food safety and hygiene practices among food vendors in a Tertiary Educational Institution in South Western Nigeria. Eur J Nutr Food Saf. 2018;8:59–70.

Lalit I, Brkti G, Dejen Y. Magnitude of hygienic practices and its associated factors of food handlers working in selected food and drinking establishments in Mekelle town, northern Ethiopia. Int Food Res J. 2015;22(6):914.

Gaungoo Y, Jeewon R. Effectiveness of training among food handlers: a review on the Mauritian Framework. Curr Res Nutr Food Sci J. 2013;1(1):01–9.

Afolaranmi TO, Hassan ZI, Misari Z, Dan EE, Judith O, Kubiat NN, et al. Food safety and hygiene practices among food Vendorsin Tertiary Hospitals Inplateau State Nigeria. World J Res Rev. 2013;25:1.

Annor GA, Baiden EA. Evaluation of food hygiene knowledge attitudes and practices of food handlers in food businesses in Accra, Ghana. Food Nutr Sci. 2011;2(08):830.

Al Suwaidi A, Hussein H, Al Faisal W, El Sawaf E, Wasfy A. Hygienic practices among food handlers in Dubai. Int J Prevent Med Res. 2012;1(3):101–8.

Rahman MM, Arif MT, Bakar K, Talib Z. Food safety knowledge, attitude and hygiene practices among the street food vendors in Northern Kuching City, Sarawak. Borneo Sci. 2016;31:94–103.

Seaman P, Eves A. Perceptions of hygiene training amongst food handlers, managers and training providers—a qualitative study. Food Control. 2010;21(7):1037–41.

Download references

Acknowledgements

The authors are grateful to all study participants, data collectors, food establishment owners and the University of Gondar for their willingness and support to the success of this study.

The authors of this study have received no funds from anywhere but the University of Gondar has covered questionnaire duplication fees.

Author information

Authors and affiliations.

Department of Environmental and Occupational Health and Safety, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

Jember Azanaw, Mulat Gebrehiwot & Henok Dagne

You can also search for this author in PubMed   Google Scholar

Contributions

JA took part in the research development proposal, data collection tools, entered data into Epi-info, analyse and interpret the data, and write various parts of the research report. MG and HD advised from the starting to the end. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Jember Azanaw .

Ethics declarations

Ethics approval and consent to participate.

We got ethical clearance from the Institutional Review Board (IRB/47/2010) of the Institution of Public Health, University of Gondar. Written informed consent was obtained from each study participants. The consent of the city administrator, the manager of the food and drinking establishments, and the respondents took part willingly. We kept the confidentiality of the respondents and for the food and drinking establishments by asking the participants not to write their names on the questionnaires and codes to conceal the identity of the food and drinking establishments. We used the collected data for this research purpose only. We forwarded health educations to the study participants by data collectors and the principal investigator at the end of the data collection.

Consent to publication

This manuscript does not contain an individual person and institutional data.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Azanaw, J., Gebrehiwot, M. & Dagne, H. Factors associated with food safety practices among food handlers: facility-based cross-sectional study. BMC Res Notes 12 , 683 (2019). https://doi.org/10.1186/s13104-019-4702-5

Download citation

Received : 10 August 2019

Accepted : 04 October 2019

Published : 22 October 2019

DOI : https://doi.org/10.1186/s13104-019-4702-5

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Food handlers
• Food safety
• Hygiene practices
• Food establishment
• Food-borne diseases

BMC Research Notes

ISSN: 1756-0500

• Submission enquiries: [email protected]
• General enquiries: [email protected]