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The hygiene training of food handlers at a teaching hospital
Food Control 19 (2008) 186–190 www.elsevier.com/locate/foodcont
The hygiene training of food handlers at a teaching hospital Cengiz Han Acikel a, Recai Ogur a, Hakan Yaren a, Ercan Gocgeldi a, Muharrem Ucar b, Tayfun Kir c,* a
Department of Public Health, Gulhane Military Medical Academy (GMMA), Ankara, 06018, Turkey b Department of Medical History and Deontology, GMMA, Ankara, 06018, Turkey c Health Department, Headquarters of South Sea Command, Izmir, 35260, Turkey Received 18 December 2005; received in revised form 16 March 2007; accepted 23 March 2007
Abstract Food-related infection is an important health problem in many countries. This study was designed as an interventional study and carried out between December 1999 and August 2000. All 83 staff, handling food at the kitchens, were included in the study. A questionnaire was developed to evaluate the level of information and self-reported behaviours of the participants before and after the training. The bacteria density of the left hand was analysed as a quantitative indicator of the subjects’ self-reported behaviours on food and personal hygiene. Following the training, the only behaviour showing a statistically significant change (p < 0.04) was using watches, jewellery, etc. during work. Total number of colonies, growing on the participants’ hands, had decreased (p > 0.05). The main way of preventing or decreasing this problem is educating food handlers and repeating this training periodically, in addition to inspection. Ó 2007 Elsevier Ltd. All rights reserved. Keywords: Food handler; Food hygiene; Training
1. Background Food-related infections constitute an important health problem in both developed and developing countries. It is estimated that 76 million food-related illnesses are seen annually in the USA. Of these episodes, 325,000 are admitted to hospital while 5000 are fatal (Mead et al., 1999). The cost of salmonellosis alone is estimated at one billion USD due to medical costs and loss of productivity. It is reported that food poisoning has been increasing in Great Britain since 1980 and that this may be due to several factors, one of which is the inadequate training of food handlers (Archer & Young, 1988). A total of 23,010 cases of dysentery has been reported in Turkey in 1997 and 3 of these have been fatal. Another 1278 cases of paratyphoid or other food poisoning have been reported with no fatalities * Corresponding author. Present address: Saglik Sube Muduru, Guney Deniz Saha Komutanligi, Balcova, Izmir, 35260, Turkey. Tel.: +90 232 238 3300; fax: +90 232 238 6000. E-mail address: [email protected] (T. Kir).
0956-7135/$ - see front matter Ó 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.foodcont.2007.03.008
(State Statistics Institute, 1999). According to Ministry of Health 23901 Salmonella typhii infection (morbidity: 33.1 per 100,000), 429 Salmonella paratyphii infection (morbidity: 0.6 per 100,000), 21,068 dysenteria infection (morbidity: 29.7 per 100,000) and 8824 Hepatitis A (morbidity: 12.4 per 100,000) was occurred in Turkey in 2004 (Ministry of Health, 2006). Increasing urbanization, industrialization and the increased population of cities leads to increased consumption of food in collective eating-places. This increases the importance of these places for public health. The preemployment training on personal hygiene, food hygiene and environmental protection measures of all those to serve in food production and repeating these sessions periodically, making the unit director responsible for personal hygiene and food hygiene and the systematic inspection of food hygiene will be helpful in decreasing losses due to food-related infections by providing preventive healthcare services and increased prevention of disease (Kir, Ucar, Gocgeldi, Kilic, & Azal, 2006; Marshall & Dickson, 1998).
C.H. Acikel et al. / Food Control 19 (2008) 186–190
Microbiological risk can be decreased significantly by preparing food properly in the kitchen. When this rule is not adhered to, kitchens can also become an important contamination point for food. The kitchen staffs therefore play an important role in food safety. CDC reports that approximately 20% of food-related infection is due to food handlers (Michaels et al., 2004). Our aim in this study was to train the staff working as food handlers at a training hospital, which is also a military hospital, on food hygiene and personal hygiene and to analyse the efficacy of the training by determining the level of knowledge and the number of bacteria growing on cultures obtained from the hands. 2. Material and method The study was designed as an interventional study and carried out at the Gulhane Military Medical Academy (GMMA) Department of Public Health between December 1999 and August 2000. A control group was not used and efficacy calculations were made using before and after values. All of the 83 members of staff working full-time with food at the GMMA Headquarters kitchens were included in the study. The training material used for the study was prepared at the GMMA Department of Public Health according to the usual rules for preparing educational material and passed preliminary trials (Tabak, 1996). A questionnaire was developed to evaluate the level of information and habits of the participants before and after the training. The questionnaire consisted of 39 questions to evaluate the level of information and habits on food hygiene and their sociodemographic characteristics. A preliminary assessment of the questionnaire was made with subjects who were food handlers from a different military facility and didn’t participate in the study. Participants complete the questionnaires by themselves under supervision of the trainer, Dr. Acikel, before and after the one-day training. The same questionnaire was administered to all participants again a month after training. The training consisted of theoretical presentations on ‘‘personal hygiene’’, ‘‘food hygiene’’ and ‘‘hand-washing’’. It was given by only one trainer (Dr. Acikel) to the participants in groups of 8, followed by a practical demonstration of proper hand-washing at the Public Health Department using interactive training techniques. The bacteria density on the left hand of the participants was evaluated as a quantitative indicator of the participants’ self-reported behaviours towards food and personal hygiene, in addition to the training. Sterile surgical gloves (the surfaces without talc were turned out in a sterile way) were filled with 20 ml of sterile Tween-80 peptone. The participants were asked to wear a glove on their left hand and to rub this hand for 3 min. These washing fluids were transferred to a sterile urine container and placed on media within 30 min. The inoculation and identification were carried out at the GATA Microbiology
187
and Clinical Microbiology Department’s laboratories. Manual methods were primarily used for identification but API kits were used for evaluating specimens, which observed atypically at microscopic screening. These four specimens were determined as Coagulase ( ) Staphylococci after evaluation by API kits. The counted colonies were converted into cfu/ml (Dokuzoguz, 1999). The hand cultures were repeated at the Department of Public Health before training and at the workplace after training. The same procedure was repeated after a month. The data were processed and statistically analysed with the SPSS for Windows V 10.0 software. Mc Nemar, Pearson chi square and paired t-tests were used for analysis of the data. The alpha error was accepted as 5% during the analyses (Acikel & Kilic, 2004). 3. Results Although, we planned to include all 83 of the foodrelated staff at the Training Hospital we could only reach 78 (94%) due to holidays and time off. Of the subjects, 67 (86%) were male and 11 (14%) female. Most had finished secondary or high school (50% and 34%, respectively). Forty-four subjects (56%) worked in preparing food as the chef or a cook, 25 (32%) served the food and 9 (12%) worked in dishwashing and cleaning (Table 1). The food handlers that attended the meeting were asked 12 questions on their self-reported behaviours regarding important behaviour while handling food before training and a month afterwards. The only statistically significant change following training was in the watch or jewellery usage habits (p < 0.05). The percentage of participants stating that they never used watches or jewellery during work was 50% before training, increasing to 80% afterwards. There was no statistically significant difference before and after training in the responses regarding the other 11 important behaviours. Although, it is not statistically significant, the increase in proportion of people who no longer rubbed their faces or hair while working (from 60% to 81%) is considerable (Table 2).
Table 1 Some descriptive characteristics of the study group Characteristics
Number
%
Sex
Male Female
67 11
86 14
Place of Birth
Ankara Other
24 54
31 69
Education status
Primary school Secondary school High school Higher education
1 27 39 11
1 35 50 14
Duty
Chef Cook Service staff Dishwashing and cleaning
7 37 25 9
9 47 32 12
188
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Table 2 Some attitudes of the study group before and after training Self-reported behaviours
Always (%)
Frequently (%)
Sometimes (%)
Rarely (%)
Never (%)
p
I I I I I I I I I I I I
BT 97 92 81 87 80 – 2.7 5.4 5.9 3.0 18 2.7
BT 1.3 6.6 14 5.9 18 – – – – 15 9.7 –
BT 1.3 1.3 1.3 2.9 1.4 – 1.4 – – 4.9 7.7 5.4
BT – – 4.0 – – 1.4 1.4 5.4 12 17 16 16
BT – – – 4.4 1.4 99 95 89 82 60 50 76
>0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 <0.05 >0.05
do not work with dirty hands clean the work area before I start work wash my hands before I start work shave daily a use a tissue when I am coughing or sneezing chew gum, etc. while working sit on benches, etc. use my apron as a towel smoke while working rub my hands on my face, hair, etc. while working use jewellery and a watch while working use the same towel to clean many places
AT 97 92 91 86 81 – 2.8 5.6 4.1 3.1 9.9 2.8
AT 1.4 2.8 8.1 6.1 17 – – 5.6 – – 1.3 5.6
AT – – – 3.0 1.4 – 1.4 – – 4.7 2.8 –
AT 1.3 1.9 1.4 – – 1.4 1.4 – 8.1 11 5.6 15
AT – 3.5 – 4.5 1.4 99 94 89 88 81 80 76
BT, before training; AT, after training. a Only male participants answered this question (n = 67).
The preliminary and final tests on the participants provided measurement of the knowledge level on food and personal hygiene before, right after and 1 month after training. The average score before training was 45.6 ± 11.2 out of 100 before training, increasing to 59.3 ± 9.8 right after training and was 56.5 ± 11.5 one month after training. The average knowledge score right after training and 1 month after training were both statistically significantly higher than the average level before training (p < 0,05) (Table 3). The type and amount of bacteria on the hands of the staff before training was determined. The most common species were Coagulase ( ) Staphylococci on the hands of 74 (95%) and Staphylococcus aureus on the hands of 58 (74%) of the 78 participants. Enterococci, Diphteroid bacilli and E. coli were also found (21%/n = 16, 19%/n = 15 and 3.9%/n = 3, respectively). One month after training, the bacteria types and numbers were determined from the hands of the participants again and the same bacteria were found at the same frequency. When the total number of colonies growing on the hands of the participants pre-training and post-training was calculated and compared, the number of colonies decreased from 108 ± 213 cfu/ml to 88 ± 134 cfu/ml. However, this difference was not statistically significant (p = 0,075). When the correlation between the knowledge score and the hand microorganism colony levels before training and 1 month after training was evaluated, there was no statistically significant difference between the pre-training knowlTable 3 The knowledge scores of the study group before, right after, and 1 month after the training
Before training Right after training One month after training
Mean
Standard deviation
pa
45.6 59.3 56.5
11.2 9.8 11.5
1.0 0.001 0.001
a The p values have been calculated by comparing with the pre-training values.
Table 4 Correlation between the pre-training and 1 month post-training knowledge scores and hand microorganism colony levels Comparison
r
p
Pre-training score–Post-training score Pre-training score–Pre-training hand colony level Pre-training score–Post-training hand colony level Pre-training hand colony level–Post-training hand colony level
0.153 0.165 0.226 0.914
0.187 0.149 0.049 0.001
edge level and the pre-training colony score and posttraining knowledge level and the post-training colony score (p > 0.05). However, there was an almost complete and statistically significant correlation between pre-training colony level and post-training colony level (R = 0.914, p < 0.05) (Table 4). 4. Discussion There are many studies on healthcare training and the training of food handlers. Our study is different in that it was on staff working in a healthcare institution and hand cultures were used as quantitative measure to determine the efficacy of the training. We did not come across any other study from Turkey evaluating the efficacy of training with this indirect measure. The participants’ level of knowledge regarding food hygiene was evaluated before, right after and a month after training and with preliminary and final tests. The level of knowledge right after and a month after training was found to statistically significantly higher than the level before training (Table 3). This indicates that periodic training on food hygiene is important to both keep the level of knowledge high by preventing the information from being forgotten and also to increase the level. We did not find a difference between pre-training and post-training self-reported behaviours with our evaluation.
C.H. Acikel et al. / Food Control 19 (2008) 186–190
The evaluation with the 12-question questionnaire showed that the only self-reported behaviour that changed statistically significantly post-training was towards ‘wearing jewellery and watches’. Pre-training, 50% of the groups stated that they did not wear jewellery or watches and this increased to 80% post-training. Many similar studies have shown that it is possible to increase the knowledge level with training but that it is much more difficult to change behaviour. Campbell et al. (1998) have reviewed 15 studies on the subject and reported that while it is difficult to change habits, training still has a positive effect on increasing food safety. Viedma Gil de Vergara, Colomer Revuelta, and Serra Majem (2000) have reported from their 1997–98 study from Valencia that training increases the knowledge level but that it is reflected less in attitudes. An Iranian study reports similar findings together with a difference between attitudes and behaviour. We are not able to evaluate this difference as our study did not observe behaviour (Askarian, Kabir, Aminbaig, Memish, & Jafari, 2004). In a study, which is very similar to this, compliance with food hygiene procedures increased after a training period. Bacterial counts significantly decreased a month after training and were not increased at 6 months (Vaz, Novo, Sigulem, & Morais, 2005). These results are very different from those from our study. The results of hand cultures that we used as a quantitative indicator of behaviour modification did not change significantly after training but there was a significant increase in the level of knowledge. A study by Dag (1996) has shown that the most common bad habits of workers at mass-production food facilities were touching their mouth with their hands, using the same towel to clean many places and to wipe their hands on their face or clothes while working. This study used observation and was different than our study. We used the food handlers’ own declarations and this should be kept in mind during evaluation. We did not find any change in the participants’ attitude on the 1-month posttraining check except for ‘using jewellery and watches’. Dag’s study (1996) has assessed behaviour 2 months post-training and did not find a statistically significant difference. Our study results are similar to this study. The isolation of enteric microorganisms from the hands is seen as an important finding for hand hygiene. We found Enteroccus in 21% and E. coli in 3.6% of our participants before training. Following training, these percentages were 21% and 5%, respectively. There was no statistically significant difference in the before and after training percentage values. This indicates that the staff did not change their behaviour markedly and that the training did not lead to behaviour modification. When the total number of microorganism colonies was evaluated, the mean number decreased from 108 cfu/ml before training to 88 cfu/ml after training. The microorganism colony number before and after training obtained from the participants’ hands was not statistically significantly different (p = 0.07). This result is consistent with
189
no marked change in the self-reported behaviours of the staff with training and support the notion that there was no behaviour modification with training. We evaluated whether there was an association between the knowledge level and hand hygiene of the participants. As shown in Table 4, there was no statistically significant difference between pre-training information level and post-training information level or the number of colonies growing in culture. However, there was a statistically significant negative correlation between the post-training information score and the number of colonies growing from the hands. It is expected that the number of colonies will decrease as the knowledge level increases. The high correlation (R = 0.914, p = 0.001) between the pre-training and post-training hand colony levels of the participants indicates that the hand hygiene of the subjects was parallel between the two measurements. When the change in the colony count and knowledge level with training was evaluated, there was no statistically significant change with training. It is unfortunate that the increased knowledge was not reflected in the behaviour but we feel this may be achieved with repeated training. A study by Furnari et al. (2002) has shown that repeated training decreased the resistance to applying the knowledge. Two studies have also investigated this matter and suggested that training be repeated every 12 months (Mathias, Sizto, Hazlewood, & Cocksedge, 1995; Riben, Mathias, Campbell, & Wiens, 1994). Our training was carried out in groups of 8 to avoid disruption of food services. The training, tests taken pre-training and post-training, obtaining cultures, administering the test again after 1 month and obtaining cultures, and the evaluation were all done separately and the results then merged. The group’s training sessions, the tests and cultures were at separate times and the staff might therefore have been influenced in some matters from their friends. The self-reported behaviours of the workers towards food hygiene were evaluated after their own declaration. Determination of behaviour of the workers by selfreported technique before education is an important limitation. It would have been better to determine these behaviours by observation. However, the fact there was no difference between the reported of behaviours before and after training indicates that we would get the same results even if we had used observation. An other important limitation is sample which restricted by the food handlers number. 5. Conclusion Food-related epidemics are important health problems for all countries. The most efficient method to stop this problem or at the very least to decrease it is by to training those working in the food industry and repeating this training periodically. The presence or absence of bacteria in the hands of food handlers was used as a quantitative indicator of their
190
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behaviour regarding food-related and personal hygiene. However, it is thought that using this method extensively will not be practical both from the application and financial points of view. It is better if those starting work related to food handling be trained on food-related and personal hygiene when they start work and at regular periods afterwards according to standard programs related to the occupation, provision of environmental hygiene, frequent checks by the employer or assignees, using legal enforcement and increasing awareness among consumers. This procedure can lead to the development of positive behaviours among the employers, their assignees and the workers. References Acikel, C. H., & Kilic, K. (2004). Method selection for medical researches. Turkish Armed Forces Preventive Medicine Bulletin, 3(7), 162–163. Archer, D., & Young, F. E. (1988). Contemporary issues: Diseases with a food vector. Clinical Microbiology Reviews, 1(4), 377–398. Askarian, M., Kabir, G., Aminbaig, M., Memish, Z. A., & Jafari, P. (2004). Knowledge, attitudes, and practices of food service staff regarding food hygiene in Shiraz, Iran. Infection Control and Hospital Epidemiology, 25(1), 16–20. Campbell, M. E., Gardner, C. E., Dwyer, J. J., Isaacs, S. M., Krueger, P. D., & Ying, J. Y. (1998). Effectiveness of public health interventions in food safety: A systematic review. Canadian Journal of Public Health, 89(3), 197–202. Dag, A. (1996). Effect of hygiene training program developed for mass feeding services on information, attitudes and behaviour. Master of Science Thesis, Ankara. Dokuzoguz, B. (1999). Isolation methods. In hospital infections. In M. Bakir, M. Akova, & I. Dokmetas (Eds.), Advanced Physician Training Course Book (pp. 211–216). Ankara: Onder Matbaasi. Furnari, G., Molino, N., Bruno, S., Quaranta, G., Laurenti, P., & Ricciardi, G. (2002). Efficacy and critical implications of food
handlers’ professional training: Analysis of an experience. Annali di Igiene, 14(5), 419–426. Kir, T., Ucar, M., Gocgeldi, E., Kilic, S., & Azal, O. (2006). Evaluation of initial and examinations of food handlers in military facilities. Food Control, 17(3), 165–170. Marshall, L. D., Dickson, J. S. (1998). Ensuring food safety. In: L. M. Douglas, R. Wallace (Eds.), Maxcy-Rosenau-last public health and preventive medicine (14th ed.) (pp. 723–736). Stanford, CT: Appleton and Lange. Mathias, R. G., Sizto, R., Hazlewood, A., & Cocksedge, W. (1995). The effects of inspection frequency and food handler education on restaurant inspection violations. Canadian Journal of Public Health, 86(1), 46–50. Mead, P. S., Slutsker, L., Dietz, V., McCaig, L. F., Bresee, J. S., Shapiro, C., et al. (1999). Food-related illness and death in the United States. Emerging Infectious Diseases, 5(5), 607–625. Michaels, B., Keller, C., Blevins, M., Paoli, G., Ruthman, T., Todd, B., et al. (2004). Prevention of food worker transmission of foodborne pathogens: risk assessment and evaluation of effective hygiene intervention strategies. Food Service Technology, 4(1), 31–49. Ministry of Health. (2006). Basic Health Statistics of Turkey 2004 (Vol. 142). Ankara: Ministry of Health Publications. Riben, P. D., Mathias, R. G., Campbell, E., & Wiens, M. (1994). The evaluation of the effectiveness of routine restaurant inspections and education of food handlers: Critical appraisal of the literature. Canadian Journal of Public Health, 85(Suppl. 1), S56–S60. State Statistics Institute. (1999). Turkish Statistics Annual, 1998 (p. 170). Ankara: State Statistics Institute Publishers. Tabak, R. S. (1996). Communication and education media: Material production and effective utilization. Ankara: Hand Book. Vaz, M. L., Novo, N. F., Sigulem, D. M., & Morais, T. B. (2005). A training course on food hygiene for butchers: measuring its effectiveness through microbiological analysis and the use of an inspection checklist. Journal of Food Protection, 68(11), 2439–2442. Viedma Gil de Vergara, P., Colomer Revuelta, C., & Serra Majem, L. (2000). Assessment of the effectiveness of health training courses offered for food handlers in a health care district of Gandia, Valencia. Revista Espanola de Salud Publica, 74(3), 299–307.
The hygiene training of food handlers at a teaching hospital Cengiz Han Acikel a, Recai Ogur a, Hakan Yaren a, Ercan Gocgeldi a, Muharrem Ucar b, Tayfun Kir c,* a
Department of Public Health, Gulhane Military Medical Academy (GMMA), Ankara, 06018, Turkey b Department of Medical History and Deontology, GMMA, Ankara, 06018, Turkey c Health Department, Headquarters of South Sea Command, Izmir, 35260, Turkey Received 18 December 2005; received in revised form 16 March 2007; accepted 23 March 2007
Abstract Food-related infection is an important health problem in many countries. This study was designed as an interventional study and carried out between December 1999 and August 2000. All 83 staff, handling food at the kitchens, were included in the study. A questionnaire was developed to evaluate the level of information and self-reported behaviours of the participants before and after the training. The bacteria density of the left hand was analysed as a quantitative indicator of the subjects’ self-reported behaviours on food and personal hygiene. Following the training, the only behaviour showing a statistically significant change (p < 0.04) was using watches, jewellery, etc. during work. Total number of colonies, growing on the participants’ hands, had decreased (p > 0.05). The main way of preventing or decreasing this problem is educating food handlers and repeating this training periodically, in addition to inspection. Ó 2007 Elsevier Ltd. All rights reserved. Keywords: Food handler; Food hygiene; Training
1. Background Food-related infections constitute an important health problem in both developed and developing countries. It is estimated that 76 million food-related illnesses are seen annually in the USA. Of these episodes, 325,000 are admitted to hospital while 5000 are fatal (Mead et al., 1999). The cost of salmonellosis alone is estimated at one billion USD due to medical costs and loss of productivity. It is reported that food poisoning has been increasing in Great Britain since 1980 and that this may be due to several factors, one of which is the inadequate training of food handlers (Archer & Young, 1988). A total of 23,010 cases of dysentery has been reported in Turkey in 1997 and 3 of these have been fatal. Another 1278 cases of paratyphoid or other food poisoning have been reported with no fatalities * Corresponding author. Present address: Saglik Sube Muduru, Guney Deniz Saha Komutanligi, Balcova, Izmir, 35260, Turkey. Tel.: +90 232 238 3300; fax: +90 232 238 6000. E-mail address: [email protected] (T. Kir).
0956-7135/$ - see front matter Ó 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.foodcont.2007.03.008
(State Statistics Institute, 1999). According to Ministry of Health 23901 Salmonella typhii infection (morbidity: 33.1 per 100,000), 429 Salmonella paratyphii infection (morbidity: 0.6 per 100,000), 21,068 dysenteria infection (morbidity: 29.7 per 100,000) and 8824 Hepatitis A (morbidity: 12.4 per 100,000) was occurred in Turkey in 2004 (Ministry of Health, 2006). Increasing urbanization, industrialization and the increased population of cities leads to increased consumption of food in collective eating-places. This increases the importance of these places for public health. The preemployment training on personal hygiene, food hygiene and environmental protection measures of all those to serve in food production and repeating these sessions periodically, making the unit director responsible for personal hygiene and food hygiene and the systematic inspection of food hygiene will be helpful in decreasing losses due to food-related infections by providing preventive healthcare services and increased prevention of disease (Kir, Ucar, Gocgeldi, Kilic, & Azal, 2006; Marshall & Dickson, 1998).
C.H. Acikel et al. / Food Control 19 (2008) 186–190
Microbiological risk can be decreased significantly by preparing food properly in the kitchen. When this rule is not adhered to, kitchens can also become an important contamination point for food. The kitchen staffs therefore play an important role in food safety. CDC reports that approximately 20% of food-related infection is due to food handlers (Michaels et al., 2004). Our aim in this study was to train the staff working as food handlers at a training hospital, which is also a military hospital, on food hygiene and personal hygiene and to analyse the efficacy of the training by determining the level of knowledge and the number of bacteria growing on cultures obtained from the hands. 2. Material and method The study was designed as an interventional study and carried out at the Gulhane Military Medical Academy (GMMA) Department of Public Health between December 1999 and August 2000. A control group was not used and efficacy calculations were made using before and after values. All of the 83 members of staff working full-time with food at the GMMA Headquarters kitchens were included in the study. The training material used for the study was prepared at the GMMA Department of Public Health according to the usual rules for preparing educational material and passed preliminary trials (Tabak, 1996). A questionnaire was developed to evaluate the level of information and habits of the participants before and after the training. The questionnaire consisted of 39 questions to evaluate the level of information and habits on food hygiene and their sociodemographic characteristics. A preliminary assessment of the questionnaire was made with subjects who were food handlers from a different military facility and didn’t participate in the study. Participants complete the questionnaires by themselves under supervision of the trainer, Dr. Acikel, before and after the one-day training. The same questionnaire was administered to all participants again a month after training. The training consisted of theoretical presentations on ‘‘personal hygiene’’, ‘‘food hygiene’’ and ‘‘hand-washing’’. It was given by only one trainer (Dr. Acikel) to the participants in groups of 8, followed by a practical demonstration of proper hand-washing at the Public Health Department using interactive training techniques. The bacteria density on the left hand of the participants was evaluated as a quantitative indicator of the participants’ self-reported behaviours towards food and personal hygiene, in addition to the training. Sterile surgical gloves (the surfaces without talc were turned out in a sterile way) were filled with 20 ml of sterile Tween-80 peptone. The participants were asked to wear a glove on their left hand and to rub this hand for 3 min. These washing fluids were transferred to a sterile urine container and placed on media within 30 min. The inoculation and identification were carried out at the GATA Microbiology
187
and Clinical Microbiology Department’s laboratories. Manual methods were primarily used for identification but API kits were used for evaluating specimens, which observed atypically at microscopic screening. These four specimens were determined as Coagulase ( ) Staphylococci after evaluation by API kits. The counted colonies were converted into cfu/ml (Dokuzoguz, 1999). The hand cultures were repeated at the Department of Public Health before training and at the workplace after training. The same procedure was repeated after a month. The data were processed and statistically analysed with the SPSS for Windows V 10.0 software. Mc Nemar, Pearson chi square and paired t-tests were used for analysis of the data. The alpha error was accepted as 5% during the analyses (Acikel & Kilic, 2004). 3. Results Although, we planned to include all 83 of the foodrelated staff at the Training Hospital we could only reach 78 (94%) due to holidays and time off. Of the subjects, 67 (86%) were male and 11 (14%) female. Most had finished secondary or high school (50% and 34%, respectively). Forty-four subjects (56%) worked in preparing food as the chef or a cook, 25 (32%) served the food and 9 (12%) worked in dishwashing and cleaning (Table 1). The food handlers that attended the meeting were asked 12 questions on their self-reported behaviours regarding important behaviour while handling food before training and a month afterwards. The only statistically significant change following training was in the watch or jewellery usage habits (p < 0.05). The percentage of participants stating that they never used watches or jewellery during work was 50% before training, increasing to 80% afterwards. There was no statistically significant difference before and after training in the responses regarding the other 11 important behaviours. Although, it is not statistically significant, the increase in proportion of people who no longer rubbed their faces or hair while working (from 60% to 81%) is considerable (Table 2).
Table 1 Some descriptive characteristics of the study group Characteristics
Number
%
Sex
Male Female
67 11
86 14
Place of Birth
Ankara Other
24 54
31 69
Education status
Primary school Secondary school High school Higher education
1 27 39 11
1 35 50 14
Duty
Chef Cook Service staff Dishwashing and cleaning
7 37 25 9
9 47 32 12
188
C.H. Acikel et al. / Food Control 19 (2008) 186–190
Table 2 Some attitudes of the study group before and after training Self-reported behaviours
Always (%)
Frequently (%)
Sometimes (%)
Rarely (%)
Never (%)
p
I I I I I I I I I I I I
BT 97 92 81 87 80 – 2.7 5.4 5.9 3.0 18 2.7
BT 1.3 6.6 14 5.9 18 – – – – 15 9.7 –
BT 1.3 1.3 1.3 2.9 1.4 – 1.4 – – 4.9 7.7 5.4
BT – – 4.0 – – 1.4 1.4 5.4 12 17 16 16
BT – – – 4.4 1.4 99 95 89 82 60 50 76
>0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 <0.05 >0.05
do not work with dirty hands clean the work area before I start work wash my hands before I start work shave daily a use a tissue when I am coughing or sneezing chew gum, etc. while working sit on benches, etc. use my apron as a towel smoke while working rub my hands on my face, hair, etc. while working use jewellery and a watch while working use the same towel to clean many places
AT 97 92 91 86 81 – 2.8 5.6 4.1 3.1 9.9 2.8
AT 1.4 2.8 8.1 6.1 17 – – 5.6 – – 1.3 5.6
AT – – – 3.0 1.4 – 1.4 – – 4.7 2.8 –
AT 1.3 1.9 1.4 – – 1.4 1.4 – 8.1 11 5.6 15
AT – 3.5 – 4.5 1.4 99 94 89 88 81 80 76
BT, before training; AT, after training. a Only male participants answered this question (n = 67).
The preliminary and final tests on the participants provided measurement of the knowledge level on food and personal hygiene before, right after and 1 month after training. The average score before training was 45.6 ± 11.2 out of 100 before training, increasing to 59.3 ± 9.8 right after training and was 56.5 ± 11.5 one month after training. The average knowledge score right after training and 1 month after training were both statistically significantly higher than the average level before training (p < 0,05) (Table 3). The type and amount of bacteria on the hands of the staff before training was determined. The most common species were Coagulase ( ) Staphylococci on the hands of 74 (95%) and Staphylococcus aureus on the hands of 58 (74%) of the 78 participants. Enterococci, Diphteroid bacilli and E. coli were also found (21%/n = 16, 19%/n = 15 and 3.9%/n = 3, respectively). One month after training, the bacteria types and numbers were determined from the hands of the participants again and the same bacteria were found at the same frequency. When the total number of colonies growing on the hands of the participants pre-training and post-training was calculated and compared, the number of colonies decreased from 108 ± 213 cfu/ml to 88 ± 134 cfu/ml. However, this difference was not statistically significant (p = 0,075). When the correlation between the knowledge score and the hand microorganism colony levels before training and 1 month after training was evaluated, there was no statistically significant difference between the pre-training knowlTable 3 The knowledge scores of the study group before, right after, and 1 month after the training
Before training Right after training One month after training
Mean
Standard deviation
pa
45.6 59.3 56.5
11.2 9.8 11.5
1.0 0.001 0.001
a The p values have been calculated by comparing with the pre-training values.
Table 4 Correlation between the pre-training and 1 month post-training knowledge scores and hand microorganism colony levels Comparison
r
p
Pre-training score–Post-training score Pre-training score–Pre-training hand colony level Pre-training score–Post-training hand colony level Pre-training hand colony level–Post-training hand colony level
0.153 0.165 0.226 0.914
0.187 0.149 0.049 0.001
edge level and the pre-training colony score and posttraining knowledge level and the post-training colony score (p > 0.05). However, there was an almost complete and statistically significant correlation between pre-training colony level and post-training colony level (R = 0.914, p < 0.05) (Table 4). 4. Discussion There are many studies on healthcare training and the training of food handlers. Our study is different in that it was on staff working in a healthcare institution and hand cultures were used as quantitative measure to determine the efficacy of the training. We did not come across any other study from Turkey evaluating the efficacy of training with this indirect measure. The participants’ level of knowledge regarding food hygiene was evaluated before, right after and a month after training and with preliminary and final tests. The level of knowledge right after and a month after training was found to statistically significantly higher than the level before training (Table 3). This indicates that periodic training on food hygiene is important to both keep the level of knowledge high by preventing the information from being forgotten and also to increase the level. We did not find a difference between pre-training and post-training self-reported behaviours with our evaluation.
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The evaluation with the 12-question questionnaire showed that the only self-reported behaviour that changed statistically significantly post-training was towards ‘wearing jewellery and watches’. Pre-training, 50% of the groups stated that they did not wear jewellery or watches and this increased to 80% post-training. Many similar studies have shown that it is possible to increase the knowledge level with training but that it is much more difficult to change behaviour. Campbell et al. (1998) have reviewed 15 studies on the subject and reported that while it is difficult to change habits, training still has a positive effect on increasing food safety. Viedma Gil de Vergara, Colomer Revuelta, and Serra Majem (2000) have reported from their 1997–98 study from Valencia that training increases the knowledge level but that it is reflected less in attitudes. An Iranian study reports similar findings together with a difference between attitudes and behaviour. We are not able to evaluate this difference as our study did not observe behaviour (Askarian, Kabir, Aminbaig, Memish, & Jafari, 2004). In a study, which is very similar to this, compliance with food hygiene procedures increased after a training period. Bacterial counts significantly decreased a month after training and were not increased at 6 months (Vaz, Novo, Sigulem, & Morais, 2005). These results are very different from those from our study. The results of hand cultures that we used as a quantitative indicator of behaviour modification did not change significantly after training but there was a significant increase in the level of knowledge. A study by Dag (1996) has shown that the most common bad habits of workers at mass-production food facilities were touching their mouth with their hands, using the same towel to clean many places and to wipe their hands on their face or clothes while working. This study used observation and was different than our study. We used the food handlers’ own declarations and this should be kept in mind during evaluation. We did not find any change in the participants’ attitude on the 1-month posttraining check except for ‘using jewellery and watches’. Dag’s study (1996) has assessed behaviour 2 months post-training and did not find a statistically significant difference. Our study results are similar to this study. The isolation of enteric microorganisms from the hands is seen as an important finding for hand hygiene. We found Enteroccus in 21% and E. coli in 3.6% of our participants before training. Following training, these percentages were 21% and 5%, respectively. There was no statistically significant difference in the before and after training percentage values. This indicates that the staff did not change their behaviour markedly and that the training did not lead to behaviour modification. When the total number of microorganism colonies was evaluated, the mean number decreased from 108 cfu/ml before training to 88 cfu/ml after training. The microorganism colony number before and after training obtained from the participants’ hands was not statistically significantly different (p = 0.07). This result is consistent with
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no marked change in the self-reported behaviours of the staff with training and support the notion that there was no behaviour modification with training. We evaluated whether there was an association between the knowledge level and hand hygiene of the participants. As shown in Table 4, there was no statistically significant difference between pre-training information level and post-training information level or the number of colonies growing in culture. However, there was a statistically significant negative correlation between the post-training information score and the number of colonies growing from the hands. It is expected that the number of colonies will decrease as the knowledge level increases. The high correlation (R = 0.914, p = 0.001) between the pre-training and post-training hand colony levels of the participants indicates that the hand hygiene of the subjects was parallel between the two measurements. When the change in the colony count and knowledge level with training was evaluated, there was no statistically significant change with training. It is unfortunate that the increased knowledge was not reflected in the behaviour but we feel this may be achieved with repeated training. A study by Furnari et al. (2002) has shown that repeated training decreased the resistance to applying the knowledge. Two studies have also investigated this matter and suggested that training be repeated every 12 months (Mathias, Sizto, Hazlewood, & Cocksedge, 1995; Riben, Mathias, Campbell, & Wiens, 1994). Our training was carried out in groups of 8 to avoid disruption of food services. The training, tests taken pre-training and post-training, obtaining cultures, administering the test again after 1 month and obtaining cultures, and the evaluation were all done separately and the results then merged. The group’s training sessions, the tests and cultures were at separate times and the staff might therefore have been influenced in some matters from their friends. The self-reported behaviours of the workers towards food hygiene were evaluated after their own declaration. Determination of behaviour of the workers by selfreported technique before education is an important limitation. It would have been better to determine these behaviours by observation. However, the fact there was no difference between the reported of behaviours before and after training indicates that we would get the same results even if we had used observation. An other important limitation is sample which restricted by the food handlers number. 5. Conclusion Food-related epidemics are important health problems for all countries. The most efficient method to stop this problem or at the very least to decrease it is by to training those working in the food industry and repeating this training periodically. The presence or absence of bacteria in the hands of food handlers was used as a quantitative indicator of their
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behaviour regarding food-related and personal hygiene. However, it is thought that using this method extensively will not be practical both from the application and financial points of view. It is better if those starting work related to food handling be trained on food-related and personal hygiene when they start work and at regular periods afterwards according to standard programs related to the occupation, provision of environmental hygiene, frequent checks by the employer or assignees, using legal enforcement and increasing awareness among consumers. This procedure can lead to the development of positive behaviours among the employers, their assignees and the workers. References Acikel, C. H., & Kilic, K. (2004). Method selection for medical researches. Turkish Armed Forces Preventive Medicine Bulletin, 3(7), 162–163. Archer, D., & Young, F. E. (1988). Contemporary issues: Diseases with a food vector. Clinical Microbiology Reviews, 1(4), 377–398. Askarian, M., Kabir, G., Aminbaig, M., Memish, Z. A., & Jafari, P. (2004). Knowledge, attitudes, and practices of food service staff regarding food hygiene in Shiraz, Iran. Infection Control and Hospital Epidemiology, 25(1), 16–20. Campbell, M. E., Gardner, C. E., Dwyer, J. J., Isaacs, S. M., Krueger, P. D., & Ying, J. Y. (1998). Effectiveness of public health interventions in food safety: A systematic review. Canadian Journal of Public Health, 89(3), 197–202. Dag, A. (1996). Effect of hygiene training program developed for mass feeding services on information, attitudes and behaviour. Master of Science Thesis, Ankara. Dokuzoguz, B. (1999). Isolation methods. In hospital infections. In M. Bakir, M. Akova, & I. Dokmetas (Eds.), Advanced Physician Training Course Book (pp. 211–216). Ankara: Onder Matbaasi. Furnari, G., Molino, N., Bruno, S., Quaranta, G., Laurenti, P., & Ricciardi, G. (2002). Efficacy and critical implications of food
handlers’ professional training: Analysis of an experience. Annali di Igiene, 14(5), 419–426. Kir, T., Ucar, M., Gocgeldi, E., Kilic, S., & Azal, O. (2006). Evaluation of initial and examinations of food handlers in military facilities. Food Control, 17(3), 165–170. Marshall, L. D., Dickson, J. S. (1998). Ensuring food safety. In: L. M. Douglas, R. Wallace (Eds.), Maxcy-Rosenau-last public health and preventive medicine (14th ed.) (pp. 723–736). Stanford, CT: Appleton and Lange. Mathias, R. G., Sizto, R., Hazlewood, A., & Cocksedge, W. (1995). The effects of inspection frequency and food handler education on restaurant inspection violations. Canadian Journal of Public Health, 86(1), 46–50. Mead, P. S., Slutsker, L., Dietz, V., McCaig, L. F., Bresee, J. S., Shapiro, C., et al. (1999). Food-related illness and death in the United States. Emerging Infectious Diseases, 5(5), 607–625. Michaels, B., Keller, C., Blevins, M., Paoli, G., Ruthman, T., Todd, B., et al. (2004). Prevention of food worker transmission of foodborne pathogens: risk assessment and evaluation of effective hygiene intervention strategies. Food Service Technology, 4(1), 31–49. Ministry of Health. (2006). Basic Health Statistics of Turkey 2004 (Vol. 142). Ankara: Ministry of Health Publications. Riben, P. D., Mathias, R. G., Campbell, E., & Wiens, M. (1994). The evaluation of the effectiveness of routine restaurant inspections and education of food handlers: Critical appraisal of the literature. Canadian Journal of Public Health, 85(Suppl. 1), S56–S60. State Statistics Institute. (1999). Turkish Statistics Annual, 1998 (p. 170). Ankara: State Statistics Institute Publishers. Tabak, R. S. (1996). Communication and education media: Material production and effective utilization. Ankara: Hand Book. Vaz, M. L., Novo, N. F., Sigulem, D. M., & Morais, T. B. (2005). A training course on food hygiene for butchers: measuring its effectiveness through microbiological analysis and the use of an inspection checklist. Journal of Food Protection, 68(11), 2439–2442. Viedma Gil de Vergara, P., Colomer Revuelta, C., & Serra Majem, L. (2000). Assessment of the effectiveness of health training courses offered for food handlers in a health care district of Gandia, Valencia. Revista Espanola de Salud Publica, 74(3), 299–307.