Food Control 27 (2012) 289e293
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Knowledge, attitude and practices regarding food hygiene and sanitation of food handlers in Kuala Pilah, Malaysia Noor-Azira Abdul-Mutalib a, Mohammad-Faid Abdul-Rashid b, Shuhaimi Mustafa c, Syafinaz Amin-Nordin a, Rukman Awang Hamat a, d, Malina Osman a, * a
Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia Kuala Pilah Health Office, 72000 Kuala Pilah, Negeri Sembilan, Malaysia Department of Microbiology, Faculty of Biotechnology and Biomolecular Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia d Diagnostic Nuclear Imaging Centre, University Putra Malaysia, 43400 Serdang, Selangor, Malaysia b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 19 January 2012 Received in revised form 30 March 2012 Accepted 3 April 2012
This study evaluates the knowledge, attitude and practices (KAP) of food handlers working in restaurants in Kuala Pilah, Malaysia. Data were collected in 2010 involving 64 food handlers. The results show that the food handlers have excellent knowledge and attitude, and good practices toward food hygiene with mean score (SD) of 83.98 (13.26), 82.8 (10.94) and 77.04 (14.98), respectively. There is significant correlation between educational level and attitude (p ¼ .008), knowledge and attitude (p .001), knowledge and practice (p ¼ .007) and attitude and practice (p ¼ .041). Even though the result shows satisfactory KAP levels of the food handlers, some aspects on hygiene measures like refreezing food item, clean working area and wearing of jewelry and watch need to be emphasized. Ó 2012 Elsevier Ltd. All rights reserved.
Keywords: Food handlers Knowledge Attitudes Practices
1. Introduction Foodborne diseases have caused a significant morbidity and mortality around the world. The United States of America reports that around 76 million foodborne diseases occur annually with 325,000 people hospitalized and 5200 cases of mortality (Buzby & Roberts, 2009). WHO also reports that 18% of children aged below 5 years old in developing countries die due to diarrhea globally (Bryce, Boschi-Pint, Shibuya, Black, & the WHO Child Health Epidemiology Reference Group, 2005). In one study food handlers were identified as the main cause of food contamination (Campos et al., 2009). The food industry in Kuala Pilah also is increasing. Due to the fast pace of living, most people take advantage of eating in restaurants and buying readymade food (Haryani et al., 2007). However, food contamination by food handlers could occur and leading to foodborne diseases if they neglect proper food handling practices in their premises. In Malaysia setting food handlers or the merchants that need a license or to renew their license need to attend courses on food handling. During the courses food handlers will be exposed on the causes of foodborne diseases, the agent of transmission, the importance of personal hygiene and the correct food handling * Corresponding author. Tel.: þ603 89472366, þ6013 6298572 (H/p); fax: þ603 89413802. E-mail address:
[email protected] (M. Osman). 0956-7135/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.foodcont.2012.04.001
practices. According to information from the Ministry of Health Malaysia (2010), there has been an increase in the incidence rate of foodborne diseases from 2005 to 2008. In 2009 the incidence rate decreased, however, death due to foodborne diseases was reported in that year with the same mortality rate as 2008. The hands of food handlers can be the vector to spread harmful microorganism through cross contamination (Bas¸, Ersun, & Kıvanç, 2006). This can occur if they ignore the importance of washing hand during food preparation. Some of the bacteria that can be found on the hands of food handlers are Escherichia coli and Staphylococcus aureus (Lues & Tonder, 2007). Food handlers can also spread harmful microorganism during and after they experience gastrointestinal infection (Bas¸ et al., 2006). Food handlers should have excellent hygiene practice to ensure cross contamination can be reduced, thus protecting the consumers from foodborne diseases. To ensure food handlers practice the correct way of handling food, knowledge and training are essential as part of their job (Martins, Hogg, & Otero, 2012). Previous studies have assessed the important of knowledge, attitude and practices among food handlers (Ansari-Lari, Soodbakhsh, & Lakzadeh, 2010; Bas¸ et al., 2006; Gomes-Neves, Araújo, Ramos, & Cardoso, 2007; Martins et al., 2012). This shows that the assessment is very crucial to provide sufficient data for further action. The purpose of this study was to evaluate the knowledge, attitude and practices of food handlers in Kuala Pilah, Malaysia and to
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N.-A. Abdul-Mutalib et al. / Food Control 27 (2012) 289e293 Table 1 Distribution of sociodemographic characteristics of the respondents (N ¼ 64). Variables
n (%)
Gender Male Female Race Malay Others Age group Youth Adult Educational level Lower educational level Higher educational level Experienced level Inexperienced Experienced Food premise grade High grade food premises Low grade food premises
16 (25) 48(75) 64 (100) 0 (0) 46 (71.9) 18 (28.1) 44 (68.8) 20 (31.2) 23 (35.9) 41 (64.1) 29 (45.3) 35 (54.7)
determine the significant relationship between the sociodemographic characteristics of the food handlers and their KAP level. 2. Methods The study was conducted among 64 food handlers from various food premises in Kuala Pilah, Malaysia. The respondents were selected through purposive sampling with technical assistance from staff of Kuala Pilah District Health Office (Health Inspector) during routine food premise inspection. Self-administered questionnaire were used in the study, and it was based on and modified from previous research (Acikel et al., 2008; Gomes-Neves et al., lu, Bilge, & Dedeler, 2009). The 2007; Tokuç, Ekuklu, Berberog content validation of the questionnaires was done by cross reference and verification from the experts in the identified field. Reliability of the questionnaires had also been tested among staff and students in local university with Cronbach’s alpha for each set of the questions range within acceptable limit (>.8). The assessments evaluated the KAP of the food handlers on food preparation, reheating food, food storage, working area, handling raw and cooked food and others. Table 2 Food handlers’ knowledge on food hygiene and sanitation. Statements
Correct answers (%)
Incorrect answers (%)
Preparation of food in advance is more likely to contribute to food poisoning. Reheating food is more likely to contribute to food contamination. An incorrect application of cleaning and sanitization procedures for equipment (refrigerator, slicing machine, mincer) increase the risk of foodborne disease to consumers. Washing hands before handling food reduce the risk of contamination. Wearing gloves while handling food reduce the risk of transmitting infection to consumers and staff. The use of cap, masks, protective gloves and adequate clothing can reduce the risk of food contamination. The importance to know the temperature of the refrigerator/ freezer to reduce the risk of food spoilage. Improper storage of foods may cause health hazard to consumers.
73.4
26.6
71.9
28.1
96.9
3.1
98.4
1.6
64.1
35.9
93.8
6.2
76.6
23.4
92.2
7.8
Table 3 Food handlers’ attitude toward food hygiene and sanitation. Statements Work area must be cleaned before start working. Hands should be washed before start working. Working with dirty hands should be avoided. We must cover our mouth and nose when coughing or sneezing. Apron can be used as a towel to clean hand. We should not smoke while working. We should not rub our hands on face, hair, etc. while working. Jewelry (including wedding ring) and a watch can be worn while handling food. The same towel can be used to clean many places. Raw food and cooked food not necessarily be separated. Separate kitchen utensils must be used to prepare raw and cooked food. Defrosted food should not be refrozen. Food should not be touched with wounded hand.
Disagree (%)
Uncertain (%)
Agree (%)
0
0
100
0
0
100
7.8
0
92.2
3.1
0
96.9
81
9.5
9.5
12.5
0
87.5
3.1
6.2
90.6
70.3
20.3
9.4
93.8
0
6.2
87.5
1.6
10.9
17.2
20.3
62.5
51.6
31.2
17.2
4.7
0
95.3
The respondents’ sociodemographic characteristics, such as gender, age, educational level, work duration and premise grades were collected during the study. The age groups were classified according to “youth” (17e35 years old) and “adult” (36 years old and above), have “low educational level” (received education up to secondary level) and “high educational level” (that received education after their secondary level), “experienced” (work for one year and more) and “inexperienced” (working for less than one year), and work in high grade premises (grade A and B) and low grade premises (grade C and no grade). Knowledge section consists of 8 questions. Respondents were required to choose ‘yes’ or ‘no’ answers for this section. Thirteen questions were constructed for attitude section. The respondents were required to choose one of the five options provided which are ‘strongly agree’, ‘agree’, ‘not sure’, ‘disagree’ and ‘strongly disagree’. For both knowledge and attitude part the correct answers were converted to 100% and marks below 50% was considered low knowledge or attitude, 50%e74.99% was considered acceptable Table 4 Food handlers’ practices toward food hygiene and sanitation. Statements
Yes (%)
No (%)
I I I I I I I I I I I
100 100 60.9 1.6 25.0 4.7 25.0 54.7 43.8 14.1 79.7
0 0 39.1 98.4 75.0 95.3 75.0 45.3 56.2 85.9 20.3
26.6 3.1
73.4 96.9
clean the work area before I start work. wash my hands before I start work. use a tissue when I am coughing or sneezing. chew gum while working. use my apron as a towel to clean my hand. smoke while working. rub my hands on my face, hair, etc. while working. use jewelry and a watch while working. use the same towel to clean many places. do not separate raw food with cooked food. use separate kitchen utensils to prepare raw and cooked food. I do not refreeze defrosted foods. I touch food that does not wrapped up with wounded hand.
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Table 5 The relationship of food handlers’ knowledge level and their sociodemographic characteristics. Variables
Gender Male Female Age group Adult Youth Educational level Higher Lower Experience level Experienced Inexperienced
c2
P
Prevalence ratio (C.I)
.043
.836
1.195 (.222e6.442)
18 (28.1) 46 (71.9)
1.380
.240
.427 (.100e1.816)
15 (75) 40 (90.9)
20 (31.2) 44 (68.8)
2.880
.090
.300 (.071e1.269)
36 (87.8) 19 (82.6)
41 (64.1) 23 (35.9)
.329
.566
1.516 (.364e6.318)
Knowledge level
n (%)
Acceptable
Excellent
2 (12.5) 7 (14.6)
14 (87.5) 41 (85.4)
16 (25) 48 (75)
4 (22.2) 5 (10.9)
14 (77.8) 41 (89.1)
5 (25) 4 (9.1) 5 (12.2) 4 (17.4)
knowledge and attitude and marks 75% and above was considered excellent knowledge and attitude. The practice section consists of 13 items. Respondents were required to choose ‘yes’ or ‘no’ answers. The marks were converted to poor (marks below 50%) and good practice (50% and above). Data were analyzed using SPSS software version 16. Chi-square test was used to determine the relationship between the sociodemographic characteristics of the food handlers and their KAP level. Logistic regression was used to determine the predictor variables for food handlers KAP level. 3. Results and discussion The results show that 75% of the respondents were female, whereas youth comprise 71.9%. Almost 70% have lower educational level, 64.1% are experienced food handlers and 54.7% work in low grade food premises (Table 1). Tables 2e4 show the KAP results of the respondents. After converting the scores to 100 points, the mean score (SD) for food handlers’ knowledge, attitude and practice are 83.98 (13.26), 82.8 (10.94) and 77.04 (14.98), respectively. More than 90% of the respondents answered the questions regarding cleaning agents and sanitization procedures, washing hands, the use of proper clothing, and the proper way to store foods correctly. This is in accordance with the study by Ansari-Lari et al. (2010) that showed a high level of knowledge on general sanitary measures among food handlers. However, 36% of the respondents gave incorrect responses regarding usage of gloves while handling food. This might due to the fact that gloves are seldom used during food preparation. There is also an acceptable knowledge among the respondents about the
process of reheating and preparing food. In has been the trend in food service establishments especially in self service restaurants to cook the food earlier. Some of them use water bath to keep the food hot and reduce multiplication of harmful microorganisms but others just let the dishes on the shelves or tables for a long period of time. This action will lead to food contamination and allow the growth of microorganisms. A study by Gomes-Neves et al. (2007) found that food handlers did not take into account the importance of temperature control during cooking and storing of food. The majority of the food handlers have positive attitudes on most of aspects such as clean working area, hand hygiene and food preparation. Nevertheless, about 30% of the respondents either agree or are uncertain about wearing jewelry and watch while handling food. Almost 40% of the respondents disagree or are uncertain about preparing raw and cooked food separately (Table 3). Using the same kitchen utensils like cutting board or knife to prepare food can cause cross contamination between raw and cooked or ready to eat food. Even though the food handlers had attended courses which emphasize the importance of using separate kitchen utensils, a few of them can easily forget about it or simply ignoring the fact. Some of the food premises were supplied with limited number of kitchen utensils like cutting board which required them to use the same items while preparing food. The usage of gloves is also important but only a few of food handlers use gloves during food preparation due to Malaysian hot climate which can cause discomfort if worn for a long period. However, gloves can also become a source of contamination through contact of raw material and other kitchen surfaces (Liu & Su, 2006). Unsurprisingly, about 83% of the respondents agree or are uncertain about refreezing defrosted food. It has been a usual
Table 6 The relationship of food handlers’ attitude level, and their sociodemographic characteristics and knowledge level. Variables
Gender Male Female Age group Adult Youth Educational level Higher Lower Experienced level Experienced Inexperienced Knowledge level Excellent Acceptable
Attitude level
n (%)
Acceptable
Excellent
4 (25) 9 (18.8)
12 (75) 39 (81.2)
16 (25) 48 (75)
1 (5.6) 12 (26.1)
17 (94.4) 34 (73.9)
8 (40) 5 (11.4)
c2
P
Prevalence ratio (C.I)
.290
.590
.692 (.181e2.654)
18 (28.1) 46 (71.9)
3.369
.066
6.000 (.719e50.059)
12 (60) 39 (88.6)
20 (31.2) 44 (68.8)
6.966
.008
.192 (.053e.699)
10 (24.4) 3 (13)
31 (75.6) 20 (87)
41 (64.1) 23 (35.9)
1.172
.279
.465 (.114e1.900)
7 (12.7) 6 (66.7)
48 (87.3) 3 (33.3)
55 (85.9) 9 (14.1)
13.902
.000
13.714 (2.778e67.705)
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Table 7 Logistic regression predicting food handlers’ attitude with educational and knowledge level as independent variables. Variable
Wald c2
P value
Adjusted odds ratio
Intercept Educational level Knowledge
3.459 4.055 8.172
.063 .044 .004
.359 .229 11.704
Table 9 Logistic regression predicting food handlers’ practice with knowledge level as independent variable.
95% CI
.055e.961 2.167e63.217
practice to thaw a whole piece of food item but using only a portion of it and refreezing the rest of the food to be used later. Thawing and refreezing food increase the number of microorganism in the food item. During thawing process, the temperature reaches a suitable condition for bacteria multiplication and refreezing the food item creates a dormant condition for this bacteria. If this process is repeated several times, the number of bacteria will increase each time and might cause hazards. Several studies by Buccheri et al. (2007) and Tokuç et al. (2009) also report similar results. The score for practice section is lower compared to knowledge and attitude section (Table 4). Most of the respondents have good practice whereby all of the food handlers clean the working area and wash their hands before they start working. However, 25% of them use apron to clean hands and rub their hands on their body parts while working. More than 40% wear jewelry while working and use the same towel to clean many places. In addition, 73.4% of the respondents refreeze defrosted food. The result shows that even though the score for knowledge and attitude section was high, the food handlers did not entirely perform hygiene practices. Studies by Ansari-Lari et al. (2010) and Bas¸ et al. (2006) show relatively poor practices among the studied respondents. There was no significant association between knowledge level and the respondents’ sociodemographic characteristics (Table 5). This contradicts with a study by Siow and Norrakiah (2011) who found out that there was a significant relationship between the respondents’ knowledge level and their working experience. Respondents working for more than six years have significantly higher knowledge level compared to respondents that have less than one year working experience. Martins et al. (2012) also reported that average scores for knowledge, increases with the level of education. Educational and knowledge level showed significant relationship with attitude level (p ¼ .008) In addition, there is a significant relationship between the respondents’ attitude and knowledge
Variable
Wald c2
P value
Adjusted odds ratio
95% CI
Constant Knowledge
15.623 4.506
.000 .034
.019 15.429
e 1.234e192.964
level (p .001) (Table 6). Logistic regression shows that respondents that have low educational level have .23 times less tendency to obtain acceptable attitude level compared to the respondents that have high knowledge level. In addition, the odds ratio reveals that respondents that have acceptable knowledge level obtain 11.7 times of acceptable attitude level compared to the respondents that have high knowledge level (Table 7). The study proves that even though the respondents have high educational level, they do not necessarily have excellent attitude. However, this association shows that having good knowledge could lead to having good attitude in food hygiene and sanitation among the respective food handlers. A study by Ansari-Lari et al. (2010) found that there was a significant positive correlation between knowledge and attitude. For example a study by Acikel et al. (2008) reported that knowledge help to improve behavior regarding usage of jewelry while working. Knowledge and attitude also showed significant relationship with practice level (Table 8). Logistic regression predicts that the odds of getting poor practice level are 15.4 times higher for respondents with acceptable knowledge level than they are for respondents with excellent knowledge level (p ¼ .034) (Table 9). These findings support the evidence of having good knowledge and attitude will lead to good practice measures. However this finding contradicts with the study by Bas¸ et al. (2006) who found out that good knowledge on food safety does not necessarily leads to good handling practices. In addition Ansari-Lari et al. (2010) revealed a negative correlation between knowledge and practice and attitude and practice. This study also shows that there is no significant relationship between food handlers’ practices with gender (p ¼ .306). However, Siow and Norrakiah (2011) found that female respondents have significantly higher practice level compared to male respondents. In conclusion, this study suggests that even though the KAP level of the food handlers was satisfactory, some of the hygiene aspects need to be emphasized. Continuous education and training should strengthen food handlers’ knowledge in area which seems
Table 8 The relationship of food handlers’ practice level, and their sociodemographic characteristics and knowledge and attitude level. Variables
Gender Male Female Age group Adult Youth Educational level Higher Lower Experience level Inexperienced Experienced Knowledge level Excellence Acceptable Attitude level Excellence Acceptable
Practice level
n (%)
c2
P
Prevalence ratio (C.I)
Poor
Good
0 (0) 3 (6.2)
16 (100) 45 (93.8)
16 (25) 48 (75)
1.049
.306
.938 (.871e1.009)
0 (0) 3 (6.5)
18 (100) 43 (93.5)
18 (28.1) 46 (71.9)
1.232
.267
1.070 (.991e1.155)
2 (10) 1 (2.3)
18 (90) 43 (97.7)
20 (31.2) 44 (68.8)
1.838
.175
.209 (.018e2.456)
2 (8.7) 1 (2.4)
21 (91.3) 40 (97.6)
23 (35.9) 41 (64.1)
1.291
.256
3.810 (.326e44.495)
1 (1.8) 2 (22.2)
54 (98.2) 7 (77.8)
55 (85.9) 9 (14.1)
7.207
.007
15.429 (1.234e192.964)
1 (2.0) 2 (15.4)
50 (98.0) 11 (84.6)
51 (79.7) 13 (20.3)
4.178
.041
9.091 (.756e109.387)
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to be lacking and avoid any irrelevant information that would be regard as a waste of time (Seaman, 2010) that might reduce food handlers’ interest. In addition, education and food safety training should be provided frequently to the food service staff in order to minimize foodborne hazards. Acknowledgments We thank the staff of Kuala Pilah District Health Office for assisting in the collection of data and all respondents who participated in this research. References Acikel, C. H., Ogur, R., Yaren, H., Gocgeldi, E., Ucar, M., & Kir, T. (2008). The hygiene training of food handlers at a teaching hospital. Food Control, 19, 186e190. Ansari-Lari, M., Soodbakhsh, S., & Lakzadeh, L. (2010). Knowledge, attitudes and practices of workers on food hygienic practices in meat processing plants in Fars, Iran. Food Control, 21, 260e263. Bas¸, M., Ersun, A. S., & Kıvanç, G. (2006). The evaluation of food hygiene knowledge, attitudes, and practices of food handlers in food businesses in Turkey. Food Control, 17, 317e322. Bryce, J., Boschi-Pint, C., Shibuya, K., Black, R. E., & the WHO Child Health Epidemiology Reference Group. (2005). WHO estimates of the causes of death in children. The Lancet, 365(9465), 1147e1152. Buccheri, C., Casuccio, A., Giammanco, S., Giammanco, M., La Guardia, M., & Mammina, C. (2007). Food safety in hospital: knowledge, attitudes and prac-
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