INTRODUCTION
Food is a basic human need for the survival. Through centuries, food has been recognized as an important need for human in health and disease. It is one of the basic requirements of man as also of all living being. Every activity of man is first aimed at procurement of food.[ 1 ]
The health of people depends to a large extent on the food they eat. However, food is frequently subjected to contamination by the variety of microorganisms resulting in to human illness and has a direct extensive and important bearing on public health. These contaminations may occur at any point during the journey of food from the producer to the consumer.[ 2 ]
Food borne disease can be defined as any disease of an infectious or toxic nature caused by or thought to be caused by the consumption of food or water.[ 2 ]
Food hygiene and food safety is also one of the main problems worldwide, especially in the developing countries like India. Worldwide, even in industrialized countries, approximately 30% of all emerging infections over the past 60 years were caused by pathogens commonly transmitted through food.[ 3 ]
Food hygiene and sanitation implies cleanliness in the producing, preparing, storing, and serving of food and water. Food sanitation is an essential aspect of food preparation. It needs to be emphasized at every step of food handling and preparation.[ 3 ] The high incidence of food-borne illnesses has led to an increase in the global concern about food safety.[ 4 ] In view of this, the World Health Organization (WHO) had selected a priority area of global public health concern as the theme for World Health Day, April 7, 2015 on food safety as “From Farm to Plate, Make Food Safe.”
The WHO estimated that in developed countries up to 30% of the population suffer from food-borne diseases each year, whereas in developing countries up to 2 million deaths are estimated per year. Moreover, in developing countries up to an estimated 70% of cases of diarrheal diseases are associated with the consumption of contaminated food. The WHO estimated 16 million new cases and 600,000 deaths of typhoid fever each year.[ 5 ]
The chances of food getting contaminated depend largely on the health status of the food handlers, their personal hygiene, their knowledge of food hygiene and above all, the proper application of that knowledge.[ 1 ]
A food handler is any person who handles food, regardless whether he/she actually prepares or serves it. According to the Codex alimentarius,[ 6 ] a food handler is defined as “any person who directly handles packaged or unpackaged food, food equipment and utensils, or food contact surfaces and is therefore expected to comply with food hygiene requirements.” Unhealthy food handlers are potentially dangerous to the health of consumers and danger is magnified many folds if they are employed in educational and health institutions. They can transmit a number of food-borne diseases such as diarrhea, dysentery, cholera, typhoid and paratyphoid fevers, viral hepatitis, protozoal cysts, ova of helminthes, tuberculosis, staphylococcal and streptococcal infections, salmonellosis and many other through their hands. Food handlers are the most important sources for the transfer of the microorganisms to the food from their skin, nose, bowel, and also from the contaminated food prepared and served by them.[ 1 ]
Since medical institutions are supposed to provide a model for healthy practices including food services, it is expected that the food service establishments there should not act as source of infection for food-borne diseases. However, a number of outbreaks of food-borne illnesses have been reported from different medical college hostels from time to time resulting in illness and hospitalization of medical students and doctors. Any incidence of food-borne diseases that affect medical students and doctors can result not only in sickness absenteeism but also in case of transmission of pathogen to patients and their relatives which ultimately affect the health-care services to a great extent. This explains the importance of maintaining high food safety levels at food establishments in medical colleges and hospital campus.[ 7 ]
Education, training, and the development of food safety certification examinations are the key components in the process of ensuring that food handlers are proficient in and knowledgeable about food safety and sanitation principles.[ 8 ]
Therefore, the present study was conducted to assess knowledge, attitude, and practice (KAP) of food hygiene and safety among food handlers presently working in different eating establishments of a medical college and attached teaching hospital.
The results of this study may help in identifying proper and suitable methods for planning health education programs for food handlers that will improve their knowledge, attitude, and practices.
Aim and objective
To study the KAP of food hygiene and safety among food handlers of study area
To study the sociodemographic profile of food handlers
To study factors affecting KAP of food hygiene and safety among food handlers.
MATERIALS AND METHODS
This was a cross-sectional study conducted in among food handlers of food establishments in the premises of B. J. Medical College and Sassoon General Hospital, Pune in June–July 2017. All 105 food handlers working in the food establishments of Tertiary Medical Institute.
Sampling technique
Universal sampling method was used in this study to include all the food handlers working in the food establishments.
Selection criteria
Inclusion criteria
All the food handlers with age more than 18 years working in the food establishments of study area
Study subjects willing to participate and giving consent for the study.
Exclusion criteria
Study subjects <18 years of age (nonavailability of legal guardian)
Study subjects absent at the time of interview (even after 3 successive visits)
Study subjects not giving consent for the study
Since all 105 food handlers fulfilled the inclusion criteria, they were included in the present study.
Approval for the conduction of the study was taken from the Institutional Ethics Committee of the institute.
A semi-structured questionnaire was prepared which included sociodemographic characteristics and KAP of food hygiene and food safety were assessed.
A pilot study was undertaken among 15 study participants and questionnaire was modified accordingly. The actual study was conducted on the basis of modified questionnaire
A time schedule for face-to-face interview was prepared in consultation with the heads of food establishments giving due consideration to the feasibility of their working hours and availability of food handlers
Written informed consent was obtained from the study participants after full explanation of the study to them
Detailed questionnaire about KAP:
Knowledge
The questions on knowledge assessed the ability of the respondent’s knowledge regarding food borne illness, the fact that food handlers can cause food borne disease, necessity of protective clothes such as apron, gloves, and head-cap.
An arbitrary scoring system was devised where in nine questions were used to assess respondent’s knowledge of food hygiene and safety. There were nine items to assess the respondent’s knowledge of food safety and hygiene practice. Response to each item was “yes,” “no” or “don’t know.” One mark was given for correct answer; zero mark was given for those who gave a response of either no or “don’t know.” The total scores for each respondent were used to categorize by Tertile method as follows.(9)
Poor knowledge: 0–3, average knowledge: 4–6, good knowledge: 7–9.
Attitude
Attitude was assessed by using total of six items. Each item was assessed using the response “agree,” “disagree,” and “uncertain.” Correct answer was given one mark and zero mark was given to wrong answer. Hence, maximum points were 6 and minimum was 0. Hence, total score for each respondent were used to categorize them as unfavorable attitude: 0–3 and favorable attitude: 4–6.[ 9 ]
Practice
Similarly, a total of 15 questions were included to assess food safety and hygiene practice. Each item was assessed using the response “yes,” “no.” Those who practice “correctly” scored as one mark and “wrong” scored as zero. The total scores for each respondent were used to categorize by Tertile method as follows:
Poor practice: 0–5, average practice: 6–10, and good practice: 11–15.
Statistical analysis
Data were entered using Microsoft Excel 2007 software and was coded accordingly. It was analyzed using EPI INFOTM version 7 (Centers for Disease Control and Prevention, Atlanta, Georgia (USA)).
. For categorical variable, Chi-square or Fisher exact test was used as test of significance. For continuous variable, Pearson’s correlation was calculated. P ≤ 0.05 was taken as the level of significance.
RESULTS
Table 1 shows sociodemographic profile of the study participants. The mean age was 29.4 ± 11.02 years. Maximum 47 (44.8%) were from 18 to 25 years’ age group and least 5 (4.8%) were above 55 years of age. Out of total study participants, maximum numbers of study participants were male 86 (81.9%) and females were 19 (18.1%). Maximum 60 (57.2%) were unmarried. Maximum number of study participants were Hindu, i.e., 88 (83.8%). Majority of study participants 44 (41.9%) had only primary level education followed by 34 (32.4%) were illiterate and least, i.e., only 2 (1.9%) were educated up to graduation. According to Modified Kuppuswami Scale updated for January 2017, maximum study participants 50 (47.6%) belonged to lower middle class and least, i.e., only one (0.9%) belonged to lower class and no one belonged to upper class. Majority, i.e., 78 (80%) were working for 1–10 years, very much less, i.e., 17 (8.5%) were working for more than 10 years. Maximum study participants 67 (63.8%) worked for more than 8 h while rest of the study participants 38 (36.2%) worked for less than or equal to 8 h per day.
Table 1: Distribution of study participants according to sociodemographic factors
Knowledge, attitude, and practice of food hygiene and safety among study participants
Knowledge
The mean (standard deviation [SD]) score of knowledge 7.09 (1.76) with minimum (1) and maximum (9.0).
Attitude
The mean (SD) attitude score of the respondents was attitude 4.26 (1.91) with score minimum (0) and maximum (6.0).
Practice
The mean (SD) score of practice was 11.75 (1.62) with minimum (6) and maximum (14.0).
Table 2 shows distribution of study participants according to grade of KAP regarding food hygiene and safety. Among all the study participants with respect to knowledge, maximum study participants 71 (67.6%) had good knowledge, followed by 32 (30.5%) study participants were having average knowledge and only two (1.9%) had poor knowledge. With respect to attitude, maximum study participants 74 (70.5%) had favorable attitude and rest 31 (29.5%) had unfavorable attitude. With respect to practice, maximum study participants 82 (78.1%) had good practice followed by 23 (21.9%) study participants had average practice while none of the study participants had poor practice.
Table 2: Distribution of study participants according to grading of knowledge, attitude, and practice regarding food hygiene and safety
Table 3 shows the correlation of mean score of KAP of food hygiene and safety among study participants. By using Pearson correlation test, mean scores of knowledge and attitude (r = 0.539; P < 0.0001) and knowledge and practice (r = 0.349; P < 0.0001) while between attitude and practice (r = 0.394; P < 0.0001); the findings suggested that there were positive relationships between both knowledge and attitude and knowledge and practice, and also attitude and practice. It can be anticipated that as knowledge will increase, attitude and practice will improve accordingly.
Table 3: The correlation of mean score of knowledge, attitude, and practice of food hygiene and safety among study participants
Table 4 shows that factor like working tenure was significantly associated with knowledge (P < 0.05). While other factors such as age, gender, education, socioeconomic status, marital status, religion, and duty hours were not significantly associated with knowledge (P > 0.05). The factors such as age, marital status, socioeconomic status, working tenure, and duty hours were significantly associated with attitude of study participants (P ≤ 0.05), whereas gender, education, and religion were not significantly associated with attitude of study participants (P > 0.05). While practice is not significantly with any sociodemographic factors (P > 0.05).
Table 4: Univariate analysis of relationship between knowledge, attitude, and practice with sociodemographic factors*
DISCUSSION
The food handlers play an important role in the spread of food-borne diseases. The incidence of food-borne diseases can be greatly reduced if food handlers follow good practices and maintain a good level of personal hygiene.
In the present study, according to score of KAP, mean (SD) score of knowledge was 7.09 (1.76), with maximum study participants (67.6%) had good knowledge, followed by (30.5%) study participants were having average knowledge and only (1.9%) had poor knowledge. With respect to attitude, the mean (SD) of attitude score of the respondents was 4.26 (1.91) with maximum study participants (70.5%) had favorable attitude and rest 29.5% had unfavorable attitude. With respect to practice, the mean (SD) score of practice was 11.75 (1.62) with maximum study participants (78.1%) had good practice followed by (21.9%) study participants had average practice while none of the study participants had poor practice.
Similar findings were observed in other studies.[ 5 , 9 , 10 , 11 ] The findings were in contrast to other study[ 12 ] which had showed that the majority of food handlers had poor knowledge score on food handling practices.
Factor such as working tenure was significantly associated with knowledge (P < 0.05). While other factors such as age, gender, education, socioeconomic status, marital status, religion, and duty hours were not significantly associated with knowledge (P > 0.05). Finding are consistent with the findings of other studies.[ 9 , 13 , 14 ]
Factors such as age, marital status, socioeconomic status, working tenure and duty hours were significantly associated with attitude of study participants (P ≤ 0.05), whereas gender, education, and religion were not significantly associated with attitude of study participants (P > 0.05) similar to the results of study (Nepal) while practice is not significantly with any sociodemographic factors (P > 0.05) same as result of other study.[ 10 ]
The findings suggested that there were positive relationships between both knowledge and attitude and knowledge and practice and also attitude and practice. It can be anticipated that as knowledge will increase, attitude and practice will improve accordingly.
In the present study, maximum 47 (44.8%) study participants were from 18 to 25 years’ age group and least, i.e., 5 (4.8%) were above 55 years of age group. The mean age was 29.4 ± 11.02 years. The findings were similar to the other studies.[ 5 , 14–16 ]
Out of total study participants, maximum were male 86 (81.9%) and females were 19 (38.1%) similar to other studies.[ 5 , 9 , 16 ] In the present study, maximum study participants 60 (57.2%) were unmarried followed by 40 (38%) were married, 3 (2.9%) were widow, and rest 2 (1.9%) were divorcee/separated. The findings were similar to the results of study[ 12 , 17 ] and contrast to findings of studies.[ 18 , 19 ]
Maximum number of study participants 88 (83.8%) were Hindu similar to other study[ 15 ] while contrast to the other study[ 10 , 12 ] where maximum study participants were Muslim. Majority of the study participants 44 (41.9%) had only primary level education followed by 34 (32.4%) who were illiterate and least, i.e., only 2 (1.9%) were graduate. The findings were comparable to other studies.[ 10 , 13 , 18 ]
According to Modified Kuppuswami Scale 2017, maximum study participants 50 (47.6%) belonged to lower middle class (III) followed by 42 (40.1%) were from upper lower class (IV), 12 (11.4%) belonged to upper middle class (II) and least, i.e., 1 (0.9%) belonged to lower class and none of the study participants belonged to the upper class similar to other study[ 9 ] and contrast to other studies.[ 5 , 10 ]
In the present study, maximum study participants, i.e., 66 (62.9%) were working since 1–5 years followed by 20 (19.1%) were working since 6 to 10 years, 10 (9.5%) were working for <1 year, and 9 (8.5%) study participants were working for more than 10 years. Similar results were obtained in studies.[ 11 , 20 ]
Limitation
In this study, 105 food handlers working in a medical college and attached teaching hospital were included; hence, the findings cannot be generalized to all the food handlers.
CONCLUSION
The findings of this preliminary study may help in planning health education intervention programs for food handlers to have improvement in KAP toward food-borne diseases and food safety. Furthermore, it will in turn reduce national morbidity and mortality of food-borne diseases. Education, training, and the development of food safety certification examinations are the key components in the process of ensuring that food handlers are proficient in and knowledgeable about food safety and sanitation principles.
Ethical approval
The study was approved by the Institutional Ethics Committee.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
The authors would like to thank B. J. Medical College, Pune and owner of all the canteen in college and hospital premises. The authors would like to thank the all the food handlers of canteen their participation.
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