Food and Nutrition Sciences, 2013, 4, 245-251 http://dx.doi.org/10.4236/fns.2013.43033 Published Online March 2013 (http://www.scirp.org/journal/fns) Food Hygiene Knowledge, Attitudes and Practices of the Food Handlers in the Military Hospitals* Labib Sharif1#, Mohammad M. Obaidat1, Mohammad-Raed Al-Dalalah2 1Department of Veterinary Pathology and Public Health, Faculty of Veterinary Medicine, Jordan University of Science and Tech- nology, Irbid, Jordan; 2Department of Food Safety, Jordanian Army, Amman, Jordan. Email: #labibsharif@yahoo.com Received January 16th, 2013; revised February 16th, 2013; accepted February 24th, 2013 ABSTRACT Improper practices and lack of knowledge by food handlers are contributing factors for the spread of foodborne out- breaks. This stud y aimed to explor e the knowledge, attitude an d pr actice of food handlers in military ho spitals in Jordan. A Self completed questionnaire was answered by 200 employees; 150 military employees and 50 civilian employees in 7 Jordanian military hospitals selected randomly one from the capital Amman and two from the three provinces. The results showed that the means of the percentage scores for the knowledge, attitude, practice, were 84.82, 88.88, 89.43, respectively and the overall knowledge, attitude, practice (KAP) mean percentage score was 87.88. A significant dif- ference (P < 0.05) in these values was observed between the military and civilian employee. The mean percentage scores for knowledge, attitude and practice were 88.5, 93.2, and 91.4, respectively for military employee compared to those for civilian employee of 73.7, 75.8, and 83.5, respectively. A significant difference for the overall (KAP) mean percentage score was also observed between gender, education and specific occupation of the food handler. Female KAP percentage mean score was 90.0 and that for males was 86.6; The college or university educations employee had a mean score of 91.6 while the elementary school education employee had a mean score of 79.7; The nutritionists and cooks had statistically similar means of 91.6 but these occupations significantly differ from the waiters 84.4 and clean- ers 80.2. Keywords: Knowledge; Attitude; Practice; Food Handlers; Jordan 1. Introduction Food handlers play a major role in transmitting patho- gens passively from contaminated sources such as trans- mitting pathogens from raw meat to a ready to eat food. Food handlers may also carry some human specific food- borne pathogens such as Hepatitis A, noroviruses, ty- phoidal Salmonella, Staphylococcus aureus and Shigella sp in their hands, cuts or sores, mouth, skin and hair. Food handlers may also shed foodborne pathogens, such as E. coli O157:H7 and non-typhoidal Salmonella du ring the infectiousness period or less important during recov- ery period of a gastrointestinal sickness [1]. Todd et al. [2] formed a workgroup and analyzed 816 foodborne outbreaks where food workers have been im- plicated in the spread of foodborne diseases. They have published a series of peer-reviewed papers in the journal of food protection from 2007 to 2011. In the third publi- cation, they categorized the factor contributing to out- breaks into food worker error factors, bacterial prolifera- tion factors, and important survival factors for pathogens. The most frequently reported food worker errors were handling of food by a person either actively infected by or carrying a pathogen, bare-hand contact with food, failure to properly wash hands when necessary, insuffi- cient cleaning of processing or preparation equipment or kitchen tools. Such unhygienic practice would cause contamination of the food and cross-contamination of ready-t o- e a t ( RTE) foods [1,2]. Several studies were conducted to evaluate the food safety knowledge, attitude and practice (KAP) of food handlers in restaurants and food establishments [3-6]. Other target populations for food safety KAP studies were univer sity stud ents [7,8] and h ospitals’ staff or food handlers [9,10]. In this study, the overall knowledge, attitude and practice (KAP) scores of the food handlers in military hospitals were explored for the first time in Jor- dan. These KAP scores were compared b etween military and civilian food handlers. The identified specific unhy- gienic practice, negative attitude and lack of knowledge that increase the risk of food poison ing will be addressed in food safety training programs for food handlers. *Authors declare no conflict of int erest. #Corresponding author. Copyright © 2013 SciRes. FNS
Food Hygiene Knowledge, Attitudes and Practices of the Food Handlers in the Military Hospitals 246 2. Materials and Methods 2.1. Target Population, Setting, and Instrument for Getting the Information Food handlers in Jordanian military hospitals are the tar- get population for this study. A modified Sharif and Al- Malki (2010) questionnaire for Knowledge, attitude and practice of the food handlers was used [7]. The ques- tionnaire consisted of fifty questions divided into three parts. Part one included 15 questions about the knowl- edge, part two included 15 questions about the attitude and part three included 20 questions about the practice. All questions about knowledge and attitude were scored on a five-point scale (0 to 4) with options of strongly agrees, agree, not sure, disagree or strongly disagree. Bu t, the questions about practice were scored on a five-point scale (0 to 4) with options of always, most of the times, sometimes, rarely or never. The direction of the scale was (4 to 0) and reversed to (0 to 4) for some questions to check the validity of the responses. For dichotomous classification the scores less than 3 were categorized as a negative respon se, (Answering wrong) while the scores 3 and 4 were categorized as a positive response (Answer- ing right). The questionnaire stated clearly to the partici- pants that the information will b e used only for scientific purposes and the participants signed a consent form. 2.2. Sampling Technique A random cluster sampling was used. The military hos- pitals were stratif ied into 4 areas; n amely, A mman, N or t h - ern, Middle and Southern provinces. Seven hospitals, one from Amman and two from each of the three provinces, were selected randomly. All food handlers in the selected hospitals were asked to complete the questionnaire by themselves (Self completed questionnaire). 2.3. Data Analysis A variable file was created on SPSS version 20. The 5 point score for the variables were ranged from 0 to 4. The mean score of each question was transformed into percentage score (dividing that score by 4, the highest possible score then multiply by 100%) to simplify the presentation and interpretation of the results. Descriptive statistics were performed for each question of the knowl- edge, attitude, practice and the overall KAP mean per- centage score. One way ANOVA test was used to com- pare the mean score of knowledge, attitude, and practice among the different four educational levels, professions of the food handlers (coo k, food server, and nutritionist). Turkey’s and LSD tests were used after ANOVA to identify significant difference between the two popula- tions. The mean score of knowledge, attitude, and prac- tice were compared by t-test according to gender (Female vs Male), professional experience (High vs Low) and military vs civilian employee. The responses were also reclassified into two categorical responses yes and no (correct and incorrect response). The rate of correct re- sponses for each question was then described. 3. Results and Discussion 3.1. Demographic Characteristics A total of 200 food handlers in 7 military hospitals in Jordan were included in this study; 150 military and 50 civilian employees. The gender of surveyed food han- dlers was 125 male and 75 female with a ratio of male to female 1.66:1. The occupations of the participants were 68 waiters, 61 cooks, 51 nutritionists, and 20 cleaners. The participants worked in different geographical loca- tion in Jord an, specifically 63 in Amman, 49 in Northern Jordan, 48 in Southern Jordan, and 40 in Middle Jordan. The mean age of participants was 29.40 ± 5.60, and ages ranged between 18 to 50 years. The mean length of em- ployment was 4.08 ± 2.37 and experience ranged from 1 to 15 years (Table 1). Table 1. Demographic characteristics of food handlers in military hospitals in Jordan. Characteristic n % Mean ± SD Range Employee Category Military 150 75 NA NA Civilian 50 25 NA NA Education NA NA University 28 14 NA NA Community college 56 28 NA NA High School 104 52 NA NA Elementary 12 6 NA NA Occupation NA NA Nutritionist 51 25.5 NA NA Cleaner 20 10 NA NA Waiter 68 34 NA NA Cooker 61 30.5 NA NA Province NA NA Amman 63 31.5 NA NA South 48 24 NA NA Middle 40 20 NA NA North 49 24.5 NA NA Gender NA NA Male 125 62.5 NA NA Female 75 37.5 NA NA Age NA NA 29.4 ± 5.6 18 - 50 Years of Experience NA NA 4.08 ± 2.37 1 - 15 NA: Not Applicable. Copyright © 2013 SciRes. FNS
Food Hygiene Knowledge, Attitudes and Practices of the Food Handlers in the Military Hospitals Copyright © 2013 SciRes. FNS 247 3.2. Overall Knowledge, Attitude and Practice The food handlers in the military hospitals expressed high level of knowledge, positive attitud e and good prac- tice in food safety. The means of the percentage scores for the knowledge, attitude, practice, and overall KAP were 84.82% ± 11.71%, 88.88% ± 12.67%, 89.43% ± 9.10%, and 87.88% ± 9.61% respectively. 3.3. Food Handlers’ Knowledge In general, the food handlers’ knowledge was high with a mean percentage score of 84.83% ± 11.71%. They dem- onstrated excellent knowledge in the categories of high risk foods, foodborn e diseases, food storage temper atures, and sources of food contamination. But, they have a lack of knowledge about the proper method of thawing frozen food, where 90% thought that the correct method for thawing frozen meat and broiler is to keep them over- night at room temperature (Table 2). A study found that the particip ants h ad goo d k nowledg e on p erso n al h ygien e and definition of foodborne diseases with mean score of 93.85% and 73.85%, respectively [11]. On the contrary, their knowledge on food storage and preparation tem- peratures was poor with only 28% [11]. Another study [12] on 124 food handlers in 32 school canteens in Por- tugal, found that the food handlers displayed reasonable level of knowledge in personal hygiene and cross con- tamination, but fared worse in other areas. The level of knowledge, as in our study, was influenced by age, mo- tivation and training. On the other hand, other studies showed that food handlers have low level of knowledge about food hygien e issues. In a study that was performed in small and micro enterprises, to assess food handlers’ knowledge on food hygiene (n = 159), in South Africa, the average percentage of correct answers was 46.0% [13] and in another study in Ankara, Turkey, the mean food safety knowledge score of food handlers (n = 764) was 43.4% ± 16.3% [14]. In our study, the food hand lers correctly answer ed that foodborne pathogens cannot be observed by the naked eye. But, other studies showed that between 52.5% and 64.4% wrongly believed that they can tell if food was contaminated with food poisoning bacteria by visual, olfactory or taste checks [15-18]. Our study showed that the food handlers have a good knowledge of temperature control knowledge and they practiced such knowledge. But other studies carried out in Turkey, Portugal, United Kingdom, Slovenia and Italy demonstrated that food handlers lack the knowledge regarding temperature con- trol as a measure to reduce the risk of food poisoning [3, 9,13,15,16,18]. Temperature control of ready to eat food and cooked food are crucial steps in catering industry to prevent the growth of foodborne pathogen to an infec- tious level. Specifically, improper holding temperature and slow cooling of hot foods, promote growth of B. cereus and Cl. perfringens to disease-causing levels [19]. Moreover, improper storage of ready to eat food facili- tates the growth of Listeria monocytogenes to an infec- tious level. 3.4. Food Handlers’ Attitude The response of food handlers to the attitude question- naire on food poisoning is presented in Table 3. In gen- eral, the food handlers’ attitude toward safe food han- dling was high with mean percentage score of 88.9% ± 12.7%. Table 2. Response of food handlers in military hospitals to knowledge questions on food poisoning in Jordan. Question Positive Answer (%) Negative Answer (%) 1) Food poisoning is caused by pathogenic microbes (93.5) (6.5) 2) Eating raw or half - cooked meat is highly risky fo r food poisoning (95.5) (4.0) 3) Eating raw unwashed vegetables is highly ris ky for food poisoning (96) (4.0) 4) Food handlers with unhygienic practice could be the source for food contami n a t i o n with food poisoning pathogens (93.5) (6.5) 5) Eating covered leftover cooked food, kept at room temperature for more than 6 hours, is at high risk t o cause food poisoning (91.5) (8.5) 6) Keeping food at refrigera tor temperature helps to prevent food poisoning (98.5) (1.5) 7) Contacting ready to eat food with bare hands caus e f o o d c o n t a mination with food poisoning pathogens (93) (7.0) 8) The correct m ethod for thawing frozen meat or broiler is to keep them overnight at room temperature (10) (90) 9) Food poisoning could cause severe diseases that end in hospitalization and sometimes death (92.5) (7.5) 10) Apparently healthy food hand lers might c a r ry foodborne pathogens (79) (21) 11) Insects such as cockroa ches and flies might transmit foodborne pathogens (96) (4.0) 12) Harmful bacteria multiply quickly at room temperature (86) (14) 13) Foodborne pathogens can be seen by the eye (88) (12) 14) Vegetables should be placed on higher shelf in refrigerator than meat and poultry (85.5) (14.5) 15) Cooked food leftover should be re-heated thoroughly (96) (4.0)
Food Hygiene Knowledge, Attitudes and Practices of the Food Handlers in the Military Hospitals 248 Table 3. Response of food handlers in military hospitals to attitude questions on food poisoning in Jordan. Question Positive Answer (%) Negative Answer (%) 16) Safe food handling is an important part of my job responsibilities (93.5) (6.5) 17) Learning more about food safety through training courses is important to me (95.5) (4.0) 18) It is important to check the temperature of the refrigerator to prevent food poisoning (96) (4.0) 19) Raw foods should be kept separately from cooked foods (93.5) (6.5) 20) Food handlers can be a source of foodborne outbreaks (91.5) (8.5) 21) Wiping vegeta b l e s or fruits make them safe to be eaten (98.5) (1.5) 22) Thorough wa shing of vegetables and fruits in tap water is necessary to prevent food poisoning (93) (7.0) 23) Beards could contaminate food with foodborne pa thogens (10) (90) 24) Long fingernails could contaminate food with fo o dborne pathogens (92.5) (7.5) 25) Raw vegetables and meat should not be cut by the same knife (79) (21) 26) Raw vegetables and meat should not be cut on the same cutting board (96) (4.0) 27) Food handler s should be medically examined every six months (86) (14) 28) Wiping of f the cutting board with a clean paper towel between food items (raw meat and b read) is enough to pr e v e nt spreading of foodborne pathogens. (88) (12) 29) Before handling food, rinsing your hand with cold water is enough to get rid of the bacteria on your hands (85.5) (14.5) 30) Foodborne outbreaks are natural life event (96) (4.0) 3.5. Food Handlers’ Practice The response of food handlers to the practice questions on food safety is presented in Table 4. In general, the food handlers practiced good hygiene level with a mean percentage score of 89.4% ± 9.1%. They practiced criti- cal points in general sanitary such as hand washing (94.5% correct answers), storing cooked meat for less than 4 h at room temperature (89% correct answers), cleaning food contact surfaces (98.5% correct answers), and separating raw meat from ready-to-eat food (90% correct answers). But, 59% of the handlers wrongly prac- tice drinking raw milk (Table 4). Our study showed that the handlers practiced the food hygiene and their knowl- edge. But, other researchers [11] found that the majority of the respondents have an average practices in all parts of the questions, desp ite their good knowledg e. The high mean percentage score of food handlers in our study could be explained in addition to high knowledge is obeying the orders attitud e of military workers. This was obvious when comparing the mean score of practice of the civilian and military food handlers in the military hospitals. The mean percentage score was significantly higher (P < 0.05) in military than civilian food handlers. But, other studies showed that the extensive knowledge of the correct practices for hand hygiene do not necessar- ily result in the appliance of these methods because of the work place barriers [20,21]. These barriers come from the work staff, including inhibitory attitudes of su- pervisors and colleagues, time pressures and/or lack of staff, as well as structural factors, such as facilities and accessibility to supplies. Therefore, the training of food handlers should be carried out in multidimensional ap- proach covering social, environmental and organizational factors, and with greater focus on risk perception that may lead to unsafe practices [22-24]. Our study showed that 98.5% of the respondents practiced proper cleaning and disinfecting procedure of premises, surfaces and ut en- sils. This is crucial step in catering industry to prevent cross contamination of food. On the other sides, a study of 200 chefs in Ireland showed that 21.5% of all the re- spondents considered the use of disinfectants in sanitiz- ing worktops as unimportant step [25]. 3.6. Gender The overall KAP mean percentage score was signifi- cantly different (P < 0.05) for females and males, where females mean KAP percentage score was 90.0 ± 7.4 and that for males was 86.6 ± 10.5. The mean scores for knowledge, attitude and practice were higher for females compared to those for males (Table 5). 3.7. Education In the military hospital food handlers, the overall KAP scores were significantly (P < 0.05) affected by the levels of edu cation , wher e the a vera ge scores increased with the education level. But, there was no significant difference in the education level between the military and civilian employee. The college and university educations have statistically similar means of 90.7 ± 7.4 and 92.1 ± 5.0, respectively. But, these education levels significantly differ from the elementary (79.7 ± 13.7) and secondary educations (86.2 ± 10.4). The knowledge, attitude, and practice scores were also significantly (P < 0.05) affected Copyright © 2013 SciRes. FNS
Food Hygiene Knowledge, Attitudes and Practices of the Food Handlers in the Military Hospitals 249 Table 4. Response of food handlers in military hospitals to practice questions on food poisoning in Jordan. Hygienic practice Unhygienic practice Question n (%) n (%) 31) Do you wear gloves when you handle ready to eat food or prepare s a n d wiches? 171 (85.5) 29 (14.5) 32) Do you wash your hands with water and soap before preparing food? 189 (94.5) 11 (5.5) 33) Do you wash your hand with water and soap after using the b a t h room? 196 (98) 4 (2.0) 34) Do you work when you have diarrhea? 149 (74.5) 51 (25.5) 35) Do you work when you ha ve l esions o n your hands? 154 (77) 46 23) 36) Do you allow your finger nails to grow? 183 (91.5) 17 (8.5) 37) Do you wash vegetables and fruits before slicing the m? 197 (98.5) 3 (1.5) 38) Do you keep cooked meat or chicken at room temperature for more than 4 hours? 178 (89) 22 (11) 39) Do you clean food contact surfaces before and a ft er preparing food? 197 (98.5) 3 (1.5) 40) Do you work when you have cold? 128 (64) 72 (36) 41) Do you wash fresh vegetables and fruits in tap water before eating? 197 (98.5) 3 (1.5) 42) Do you wash your hands with water and soap before eating your meal? 191 (95.5) 9 (4.5) 43) Do you wash your hands with water and soap after handling raw meat? 198 (99) 2 (1.0) 44) Do you wash your hands with water and soap after using the toilet? 198 (99) 2 (1.0) 45) Do you dry your hands after washing them with towel? 185 (92.5) 15 (7.5) 46) Do you eat half- cooked eggs (Egg yolk is soft)? 173 (86.5) 27 (13.5) 47) Do you separa t e raw meat from ready to e a t fo od s? 180 (90) 20 (10) 48) Do you check the temperature o f the refrigerat o r? 182 (91) 18 (9.0) 49) Do you drink r a w (unpasteurized) mi l k ? 82 (41) 118 (59) 50) Do you eat half c o oked meat (inside is pink)? 188 (94) 12 (6.0) Table 5. Mean percentage score for knowledge, attitude, practice and KAP according to gender of the food handlers in military hospitals in Jordan. Character Gender n Mean SD Male 125 83.60 12.58 Knowledge percentage Female 75 86.87* 9.87 Male 125 87.31 13.62 Attitude percentage Female 75 91.49* 10.50 Male 125 88.31 10.28 Practice percentage Female 75 91.28* 6.35 Male 125 86.60 10.53 KAP percentage Female 75 90.02* 7.44 *Significant difference between the means (P < 0.05) by t-test. by the levels of education, where the average scores in- creased with the education level. Our findings corrobo- rate with other studies. For example, a study carried out in Ankara (Turkey) to determine employees’ (n = 400) perception of hygiene in the caterin g industry [14] found a significant difference among different levels of educa- tion, where participants with university education had better perception. 3.8. Occupation In the military hospital food handlers, the overall KAP score was significantly (P < 0.05) affected by type of work; where the cooks and nutritionist KAP scores were statistically similar, but waiters and cleaners were gro up ed in another group. The nutritionists and cooks had statis- tically similar means of 91.6 ± 6.0 and 91.1 ± 7.2, re- spectively. But, these occupations significantly differ from the waiters (84.4 ± 11.4) and housekeepers (80.2 ± 9.1). The KAP scores for waiters and cleaners were sta- tistically similar. The knowledge, attitude, and practice score were also significantly (P < 0.05) affected by the occupation, where the average scores for nutritionists and cookers were statistically similar, but both differ from those for waiters and housek eepers. 3.9. Professional Experience In the full questionnaire scores, no statistically signifi- cant difference was found between participants of dif- ferent experience levels. Despite the average score dif- ferences between the categories (the most experienced participants with the higher score and the less experi- enced with the lower score). But, in the group of ques- tions in which less than 50% of correspondents respond ed correctly, there is a statistically significant difference (P < 0.05) between results obtained by participants with different professional experience. Participants with more than five years of experience have higher scores than those with work experience of between one and three years (P < 0.05). Copyright © 2013 SciRes. FNS
Food Hygiene Knowledge, Attitudes and Practices of the Food Handlers in the Military Hospitals 250 3.10. Military vs Civilian Employee The overall KAP scores were significantly different (P < 0.05) for military and civilian employee; where military employees mean KAP score was 91.1 ± 8.0 and that for civilian employees was 78.3 ± 7.5. The mean scores for knowledge, attitude and practice were higher for military employee of 88.5 ± 9.8, 93.2 ± 10.2, and 91.4 ± 8.0, re- spectively compared to those for civilian employee of 73.7 ± 10.0, 75.8 ± 10.1, and 83.5 ± 9.6, respectively. There was no significant difference (P > 0.05) between the two groups in terms of education, or sex. The rates of college or university education in military and civilian employees were 43.3% and 36% respectively and the rates of female in military and civilian employees were 38.7% and 34% respectively therefore this difference in KAP scores might be attributed to the “obeying the or- der” attitude of the military employee and more food hygiene training of the military employee. This agrees with other study which confirmed that educational inter- vention improves KAP of food handlers, based on that study which involved 370 Iranian food handlers [26]. Another study [27] also found that the level of knowl- edge was higher in FOODSAFE trained food handlers compared to untrained handlers. But, they confirmed that training and recertification is needed since food safety knowledge decreased over 25 years’ period post-certifi- cation. 4. Conclusion This investigation provides valuable information about the level of knowledge, attitude, and practice in food safety of food handlers in military hospitals in Jordan. An important result from this study showed that the overall KAP scores were significantly higher (P < 0.05) in military (91.1) than in civ ilian employees (78.3). Edu- cating, training and promoting positive attitude of food handlers would improve the status of food hygiene knowledge, attitudes and practices. 5. Acknowledgements This work was supported b y the Deanship of Research at Jordan University of Science and Technology; research number 25/2012. We thank the cooperation of the mili- tary Jordanian hospitals in con ducting this study. REFERENCES [1] M. R. Adams and M. O. Moss, “Food Microbiology,” 3rd Edition, The Royal Society of Chemistry, Cambridge, 2008. [2] E. C. Todd, J. D. Greig, C. A. Bartleson and B. S. 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