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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

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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.

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Lawrence Sena Tuglo, Zhongqin Pan & Minjie Chu

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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.

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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

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

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• 1 Departamento de Ingeniería Industrial, Facultad de Ingeniería, Universidad Nacional de Asunción, Paraguay, San Lorenzo 2160, Paraguay.
• 2 Facultad de Ingeniería, Arquitectura y Diseño-Universidad Autónoma de Baja California, Ensenada 22870, Mexico.
• 3 Facultad de Ciencias Químicas e Ingeniería, Universidad Autónoma de Baja California, Tijuana 22390, Mexico.
• 4 Facultad de Ciencias de la Ingeniería, Administrativas y Sociales, Universidad Autónoma de Baja California, Tecate 21460, Mexico.
• PMID: 32854221
• PMCID: PMC7555000
• DOI: 10.3390/foods9091169

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.

Keywords: attitude; behavior; food handlers; food safety; foodborne diseases; hygiene; knowledge; practices; training.

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Health and Safety Aspects of Food Processing Technologies pp 1–8 Cite as

Management of Food Safety and Hygiene: An Overview

• Farhana Masood 4 ,
• Zarreena Siddiqui 5 ,
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• First Online: 01 November 2019

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As all human need food, its safety and nutritional quality is important. According to Codex Alimentarius Commission (CAC), Food hygiene is defined as “all conditions and measures parameter of quality to ensure the safety and suitability of food at all stages of the food chain.” Food hygiene includes 2 key points, (i) food safety and (ii) food suitability. CAC defined food safety as “the assurance that food will not cause harm to the consumer, when it is prepared and eaten according to its intended use”, while food suitability is defined as “assurance that food is acceptable for human consumption according to its intended use”. The fundamental part of any food operation is food safety. In the present era, food safety assurance is different because plethora of chemical, physical and biological agents can contaminate the food source and pose a threat not only to human health but also food business. Today there is sufficient technical and scientific knowledge, and managerial knowledge for ensuring the products safety. Presently concepts like Hazard Analysis and Critical Control Point and risk analysis are developed and incorporated in the food safety management and hygiene both nationally and internationally. In this chapter significance of food hygiene, food safety and various approaches for their management has been reviewed.

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• Risk management

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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

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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

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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.

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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.

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Correspondence to Jember Azanaw .

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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.

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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

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

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Edible grasshopper, Ruspolia ruspolia, has nutritional and cherished cultural and economic importance to people from diverse cultures, particularly in over 20 African countries. It is consumed at home or commercially traded as sautéed, deep-fried, or boiled products. However, there is limited information on the hygiene practices of the vendors and the implications on the microbial safety of the final product. This research aimed at assessing the food safety knowledge, handling practices and shelf life of edible long-horned grasshopper products among vendors and the microbial safety of ready-to-eat products sold in twelve different markets in Uganda. Samples of raw, deep-fried and boiled grasshoppers were randomly collected from 74 vendors (62% street and 38% market vendors) and subjected to microbial analysis. Over 85% of the vendors surveyed had no public health food handler's certificate and > 95% had limited post-harvest handling knowledge. Total aerobic bacteria (7.30-10.49 Log10 cfu/g), Enterobacteriaceae (5.53-8.56 Log10 cfu/g), yeasts and moulds (4.96-6.01 Log10 cfu/g) total counts were significantly high and above the acceptable Codex Alimentarius Commission and Food Safety Authority of Ireland (FSAI) limits for ready-to-eat food products. Eight key pathogenic bacteria responsible for foodborne diseases were detected and these isolates were characterized as Bacillus cereus, Hafnia alvei, Serratia marcescens, Staphylococcus aureus, S. xylosus, S. scuiri, S. haemolyticus and Pseudomonas aeruginosa. Findings from this study highlight the urgent need to create local and national food safety policies for the edible grasshopper "nsenene" subsector to regulate and guide street and market vending along the value chain, to prevent the transmission of foodborne diseases to consumers.

Keywords: Edible grasshoppers, Ruspolia differens, Food Safety, Microbial contaminants, Vendor characteristics

Received: 12 Feb 2024; Accepted: 08 Apr 2024.

Copyright: © 2024 Mugo, Imungi, Njue, Akutse, Khamis, Ombura, Diiro, TANGA and Subramanian. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: CHRYSANTUS M. TANGA, International Centre of Insect Physiology and Ecology (ICIPE), Nairobi, 00100, Kenya

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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College of Agricultural & Life Sciences

Sen. baldwin visits center for dairy research to learn how uw is supporting new dairy businesses, new faculty profile: sara gragg studies food safety issues affecting the meat industry.

Sara Gragg joined the UW–Madison faculty in January 2024 as an associate professor in the Department of Animal and Dairy Sciences. She is part of the Meat Science and Animal Biologics Discovery program.

What is your hometown? Where did you grow up? My hometown is Lincoln, Nebraska. I grew up on an acreage outside of town with horses, dogs and one cat.

What is your educational / professional background, including your previous position? I have a bachelor’s in food science and technology from the University of Nebraska-Lincoln; a master’s in food science from Texas Tech University, with an emphasis on food safety and food microbiology; and a Ph.D. in animal science from Texas Tech University, with an emphasis on food safety and food microbiology. I was previously at Kansas State University in the Department of Animal Sciences and Industry. I was also a core faculty member in the Food Science Institute. At the time of my departure in summer of 2023, I was an associate professor and about to submit my packet for promotion to full professor.

How did you get into your field of research? I was a high school student when I first learned about the food science discipline through my involvement in the FFA chapter at my high school. Students in FFA have a supervised agricultural experience (SAE) program, and it was while I was considering options for my SAE program that I became involved in food science. My agriculture teacher and FFA advisor, Dr. Todd Brashears, suggested that I meet his wife, Dr. Mindy Brashears, a food microbiologist specializing in food safety. At the time, Mindy was a faculty member at the University of Nebraska-Lincoln (UNL) with a food safety research program. I began working with Mindy and her graduate students at UNL to conduct small science fair projects for FFA and realized I have a passion for food safety research. Eventually, I was hired as a student worker and have worked in food safety ever since! I was extremely fortunate to have been mentored by Todd and Mindy Brashears (currently at Texas Tech University) from such an early age, and it was because of their mentoring that I am a food microbiologist today.

What are the main goals of your current research and outreach programs? The main goal of my research program is to address food safety issues that affect the meat industry. Some specific research goals include:

• Identifying and validating post-harvest interventions to prevent and/or reduce the presence of Salmonella or other foodborne pathogens in meat products.
• Describing the pre-harvest transmission of foodborne pathogens in food animals, including the relationship between the pathogen, the animal host and the environment.
• Characterizing Salmonella carriage in high-risk animal tissues, such as lymph nodes, and identifying opportunities for mitigation to reduce impact on public health.
• Identifying and validating pre-harvest interventions to reduce foodborne pathogens in live animals

What was your first visit to campus like? My first campus visit was a whirlwind – but a fantastic three-day experience. I specifically remember the energy I felt during my campus tour. I enjoyed the hustle and bustle of being on a campus in the middle of a busy capital city. I had great conversations with everyone I interacted with and was continually impressed by the quality of work and caliber of research underway at UW-Madison. I was also impressed by the research capabilities on campus, especially the Meat Science and Animal Biologics Discovery building that I would eventually call home at the UW–Madison. I ended my visit feeling like the UW–Madison is a place where I could thrive and take my career to the next level, and becoming a Badger has been the best decision for my career!

What’s one thing you hope students who take a class with you will come away with? Of course, the content is important in any class. However, I would argue that my most important task as an instructor is to prepare students to be effective professionals who are also good colleagues. I have high expectations, clearly communicate these expectations, and hold students accountable. When students leave my course, I want them to feel like they were challenged to grow as professionals and supported by me along the way. I also want students to feel comfortable using me as a resource throughout their careers, and I have had several former students reach out over the years, which is rewarding for me.

Do you feel your work relates in any way to the Wisconsin Idea? If so, please describe how. As a microbiologist specializing in food safety, my work embodies the Wisconsin Idea by focusing on improving public health, saving lives, supporting agriculture, and protecting our global food supply. Through my mentoring and teaching, I also recognize the importance of working to preserve the future of our agriculture industry by empowering the next generation of agriculturists to be strong leaders and always do the right thing. My collective teaching, research, and outreach efforts have not just impacted people in the state of Wisconsin, but have also focused on improving food safety nationally and internationally, including several international food safety research and outreach efforts.

The pandemic forced us all to reconsider many things we took for granted. Is there something you’ve learned that has helped you through these challenging times, personally or professionally? During the pandemic, I had young children aged six and nine. It was very difficult for my husband and me to juggle parenting and homeschooling while working full-time. I have always been a morning person, but I learned to adjust by getting up even earlier, at 4:00 or 5:00 in the morning, to get in a few hours of quiet work while the rest of my family was still sleeping. That habit became so effective that I still follow it today by getting up at 5 a.m. to take care of email and other high-focus tasks before heading to the office. I try to front-load my day so I can focus on my family and our children’s activities in the evenings. This habit has maximized my productivity, but it has also helped me to maximize my valuable family time.

What’s something interesting about your area of expertise you can share that will make us sound smarter at parties? This may not make you sound smarter at parties, but I am continually sharing it with people because it is so important for reducing foodborne illnesses in consumer kitchens: DO NOT WASH YOUR RAW MEAT AND POULTRY! This practice is a serious cross-contamination event, as it sprays bacteria in the sink, around the sink, and even on your person. This is one of my favorite resources for demonstrating why this practice is an issue: https://youtu.be/JZXDotD4p9c .

What are your hobbies and other interests? I enjoy watching and playing sports, working out, spending time outside, traveling and supporting our children in their activities. Between our two children, we cheer at band concerts, track meets, basketball games, baseball games and football games. We also enjoy playing board games as a family and playing cards with friends.

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Stay connected, additional links, 7 ways to reduce food safety violations in restaurants.

Food safety should be a culture in restaurants. Training and retraining falls on management to make sure restaurants are on the up and up during inspections.

April 8, 2024 | by Mandy Wolf Detwiler — Managing Editor, Networld Media Group

Food safety is a top concern in restaurants, but as employees get less and less training and operators begin to cut corners, food safety often becomes overlooked in the day-to-day operations of restaurants.

Most restaurants have had surprise health inspections, and those can be painful if a restaurant isn't always on their game. Heath inspections are done at the city, county or state levels depending on jurisdictions and can result in a restaurant closing for a short time while they correct infractions ranging from employee drinks on the makeline to improperly stored food items and pests in the kitchen.

According to the Center for Disease Control , the greatest causes of illnesses in restaurants stem from sick workers, poor hand hygiene and lack of certifications.

Food safety begins with proper hygiene

First and foremost, it's your employees' responsibilities to maintain proper hygiene for food safety. That includes always wearing clean and protective clothing. Hair and beards should be covered with hats and/or hair restraints.

Operators need to make sure that employees "wash their hands and sanitize their hands, especially if they leave the food prep area and they have to go to the bathroom," Esperanza Carrion, VP and general manager for Sani Professional , a cleaning solutions company, said in a phone interview. "It's very important that before they go back to the prep area that they have cleaned their hands thoroughly and have sanitized their hands. And sometimes people forget."

Practice proper surface sanitation

Carrion said the common rag and bucket used to clean surfaces in restaurants is often a cause of contamination in food safety.

"The protocol is you have to leave that rag immersed in the solution, the sanitizer. Number one, the sanitizer in that bucket is not even potent anymore because its being used and reused. (Employees) wipe the table with all the food debris or dirt. They put it back in the bucket and take out the rag again. (Contamination) gets transferred from table to table." The rag is not left inside the sanitizer.

It's preferable to use a spray bottle and a clean rag or paper towels to sanitize a surface every time.

After using a cutting board, it's imperative that the surface is sanitized before moving on to another food. This is especially important for food safety where meats are concerned.

"Before you move to the next item, you have to clean and sanitize that surface," Carrion said. She recommends cleaning in pairs so employees can be attributable to one another.

Wash foods properly

Fresh vegetables and fruits that come in from outside often carry dirt and contamination.

While some restaurants tout the use of fresh ingredients, it's especially important for food safety to wash fruits and vegetables like tomatoes, lemons and lettuce. Lemon wedges, cut for drinks like ice tea and ice water, are especially susceptible to food-borne pathogens as staff stick their hands in the container to pull out wedges without properly sanitizing their hands each time.

Maintain proper temperatures

"A huge part of food safety is the proper temperatures," Carrion said. "We have this range of temperatures for cold and hot, so that's also very, very important. You have to go for food safety first above everything else before trying to be cost or energy efficient."

Clean your equipment

While grills, fryers and stoves take center stage in QSRs, ice machines are problematic and are among the most common health code violations. Human error is a significant reason. Ice becomes contaminated with improper employee handling or improperly maintained ice machines. Unfortunately, the cold temperatures of ice machines don't kill bacteria and viruses — they slow growth. The ice could smell and taste fine but still harbor dangerous bacteria.

Walk-in refrigerators are often problems for bacteria growth and spreading, especially condensation issues. Condensation water tends to be contaminated with bacteria that can cause wither food spoilage or food-borne illnesses.

Use proper labeling

The CDC found that one in four restaurants did not label refrigerated and ready-to-eat foods with dates that tell employees when foods are no longer safe to consume. Restaurants should use date marking to help indicate when foods should not be consumed.

Foodborne pathogens like Listeria monocytogenes can still grow at refrigeration temps, especially in ready-to-eat foods like deli meats and salads. The FDA Food Code recommends these foods should not be kept after seven days of use and should be properly dated and marked.

The CDC found that chain restaurants used date marketing more often than independent restaurants, and some restaurants marked date of prep while others marked the date to throw it away. Utilizing the date to throw it away is a better method as there's less room for error.

Cross contamination can affect food safety

Cross contamination can be a nasty business, especially when dealing with raw meats. Safely cooked food can become contaminated when it comes into contact in even the slightest way with raw food. QSRs that handle raw chicken and hamburger meats should take special caution to avoid clean work surfaces.

Food allergies can also become an issue in food safety, and best practices like cleaning and sanitizing cutting and preparation tools — not just cutting boards — can make a difference. Nut allergies are especially prevalent in consumers, and sanitizing surfaces can reduce the potential for cross contamination.

Training employees becomes paramount in cross contamination. For instance, pizza restaurants that offer gluten-free pizza should use care not to use the same pans and cutting utensils as regular pizza dough.

Using a master cleaning schedule can help a restaurant weather even the sharpest of inspectors' eyes. Spread and rotate the cleaning chores so the same employees aren't cleaning the same equipment. It's a good idea to make sure they're learning how to clean different parts of the kitchen. Fresh eyes can overlook complacency and missed dirty spots.

In the QSR industry, this may be the first job for many employees, and training is critical to avoid food safety violations in restaurants.

"The turnover in the industry is very high," Carrion said. "In entry level positions, people don't stay there for long. For the managers or the operators of restaurants, there's constantly the training and retraining because you have a very high level of staffing."

Ultimately, a restaurant's food safety culture begins with management. Managers should offer food safety training as part of a new employee's training, but continual training and refreshers for all staff can reduce food-borne illnesses and the potential for inspection violations.

INCLUDED IN THIS STORY

Sani Professional

400 Chestnut Ridge Road, Woodcliff Lake, NJ, 07677 // 2017468959

FOOD SAFETY is our Passion. Making it SIMPLE is our Mission. Our broad range of easy-to-use cleaning, sanitizing, and disinfecting products help mitigate the risk of illness commonly caused by cross-contamination of surfaces, improper food handling and poor personal hygiene.

Mandy Wolf Detwiler

Mandy Wolf Detwiler is the managing editor at Networld Media Group and the site editor for PizzaMarketplace.com and QSRweb.com. She has more than 20 years’ experience covering food, people and places.   An award-winning print journalist, Mandy brings more than 20 years’ experience to Networld Media Group. She has spent nearly two decades covering the pizza industry, from independent pizzerias to multi-unit chains and every size business in between. Mandy has been featured on the Food Network and has won numerous awards for her coverage of the restaurant industry. She has an insatiable appetite for learning, and can tell you where to find the best slices in the country after spending 15 years traveling and eating pizza for a living. 

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"Safety crisis": Food delivery's simmering violence problem

Studies show couriers experience threats of violence and harassment — and often don't know where to turn, by ashlie d. stevens.

Over the past few years, the posts on r/UberEats , a subreddit dedicated, in part, to couriers’ working conditions, have increasingly centered on the threats of violence delivery drivers face. For instance, one driver posted an expletive-laced screenshot in which a customer threatened to kill them if they didn’t cancel an order-in-progress. “He called and said he was on his way to Wendy’s and looking for my car to murder me,” the courier wrote. 

Another shared an experience in which they accidentally delivered a bag of McDonald’s takeout to the wrong building within a New York City apartment complex at 2 a.m.; after informing the customer of the mistake and assuring them they’d help get a refund, the customer shouted from their second-floor window that the driver deserved “a light beating.” 

In a post from last year, titled “ In regards to the uptick in recent posts related to courier drivers being assaulted/murdered ,” one subreddit member asked other members to stop posting stories like that because they were depressing. “It's very discouraging to come here and see post after post about someone being killed, or assaulted,” they wrote. “If you guys want to discuss that, that's fine, but we can do it in one centralized thread, and not taint the overall environment of this subreddit.” 

Instead of complying, users in the comments began a conversation about how drivers are keeping themselves safe. One wrote: “I keep a gun on me at all times while doing deliveries … There are horrible people out there just waiting for someone like me, a woman, alone, doing deliveries in the middle of the night. Not on my watch fool.” 

This isn’t just an UberEats problem; as the rate of online food delivery has increased over the last five years — a trend that was then supercharged by the pandemic — new research shows that couriers are incredibly vulnerable to threats of violence, some of which have evolved into tragic national headlines. Now, some of the major food delivery providers are rolling out new technology intended to curb the rate of harassment , but will it be enough? 

"He called and said he was on his way to Wendy’s and looking for my car to murder me."

In a 2023 study from Georgetown University , which was based off of in-depth interviews with 41 DC-based food delivery workers, researchers found that 41% of the workers had experienced verbal harassment or physical assault while on the job. In total, 51% of the workers with whom researchers spoke indicated “they have felt unsafe or feared for their physical well-being while engaged in delivery work.” Additionally, workers who are Black, Hispanic or Asian were more likely than white workers to share experiences of assault and harassment. 

Many couriers also reported inaction from their employers in the face of harassment. 

For instance, in 2022, Vanessa, a full-time delivery driver interviewed by Georgetown’s research team, survived a carjacking while picking up an order from a restaurant. She was attacked from behind, but was able to get free. However, before she called emergency services, Vanessa signed into the UberEats app to un-assign herself to the delivery order because she was concerned the platform would penalize her in the future. She didn’t tell the company that she had been assaulted. 

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“I don’t think there would have been a point to report it,” Vanessa said. “I don’t think they would have done anything.” 

The researchers noted in their report that they had heard this refrain over and over again about a lack of faith in delivery companies to help workers experiencing emergencies. “We find that many workers believe, as Vanessa does, that the companies will penalize them for disrupted or incomplete orders, even if the reason for the interruption is a verbal or physical assault,” they wrote. “A recent study shows that this fear is not unfounded for the sister industry of ride-hail: Drivers are often deactivated (or fired) after they report physical assaults or verbal abuses by passengers.”

Underpinning many couriers’ concerns about threats of violence are several high-profile murder cases in which food delivery workers have been killed while on the job. Last April, for instance, an UberEats driver was slain and dismembered while making a delivery in Florida. That same month, a DoorDash delivery driver was shot and killed after an argument in Akron . 

In May 2023, the activist group Gig Workers Rising released a report that said, according to their research, 80 app-based workers have been “victims of homicides while on job between 2017 and 2022.” The majority were ride-hailing drivers, but at least 20 delivery workers were also killed, according to the report, which relied on press accounts, court records and police reports.

“Corporations like Uber, Lyft, DoorDash and Instacart have transformed transportation and meal delivery, but too many of them have done so by exploiting their workers on the job,” they write. “Their growth-at-all-costs model has repeatedly failed to adequately address the most tragic human cost of their business: loss of life.” 

They continue: “After a worker’s tragic death, the corporations for whom they worked often send ‘thoughts and prayers’ through news reporters, but do not consistently support families with basic protections like workers' compensation.This behavior is consistent with too many app corporations' core business model: cutting costs by avoiding compensation and protection of their workers. App workers are shut out of safety net programs like workers compensation and, despite how dangerous the work is, too often workers are left on their own to figure out strategies to protect themselves.” 

To help address some of these concerns, DoorDash added an AI chat feature to its app to detect harassment between workers and customers. While DoorDash has implemented safety measures before, including an “emergency button” for drivers in 2022 and an earlier version of this harassment detection technology, this new feature, SafeChat+, is more adept at detecting the nuance of messages rather than simply relying on keyword detection.

"App workers are shut out of safety net programs like workers compensation and, despite how dangerous the work is, too often workers are left on their own to figure out strategies to protect themselves."

“If SafeChat+ detects an inappropriate or abusive conversation between a consumer and Dasher, Dashers will be given the option to quickly cancel the order without impacting ratings,” DoorDash wrote in a release . “If the order is already completed, the feature will automatically end any further chat to help prevent the situation from escalating. If a Dasher uses inappropriate or abusive language with a customer during a delivery, the customer can reach out to support via chat or phone to report the incident and receive assistance.” 

However, many gig workers believe this is the very least these companies can do for employees who are often putting their lives on the line — literally — to deliver $15 worth of food. For instance, Gig Workers Rising maintains that while “murder is the extreme, the norm is exploitation.” 

As such, the group issued a set of demands that go beyond in-app support, including compensation, no forced arbitration in the case of lawsuits, transparency about the rate of worker deaths and violent incidents and the ability to unionize. 

“That this safety crisis is allowed to continue unabated is a function of too many corporations' business model — cutting costs by displacing cost and risk on to workers, and leaving families and workers on their own, even in the extreme case of workers being murdered on the job,” they write. 

about this topic

• Woman rescued from violent hostage situation after using Grubhub order to contact local police
• After algorithm shift, Uber Eats couriers without cars report dwindling wages
• DoorDash drivers make an average of $1.45 an hour, analysis finds

Ashlie D. Stevens is Salon's food editor. She is also an award-winning radio producer, editor and features writer — with a special emphasis on food, culture and subculture. Her writing has appeared in and on The Atlantic, National Geographic’s “The Plate,” Eater, VICE, Slate, Salon, The Bitter Southerner and Chicago Magazine, while her audio work has appeared on NPR’s All Things Considered and Here & Now, as well as APM’s Marketplace. She is based in Chicago.

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