Background: Good personal hygiene and sanitary handling practices at work are an essential part of any prevention program for food safety. Objective: This study conducted to investigate short- and long-term effect of public health training courses on knowledge, attitude, and practice of managers and food handlers in Kermanshah city. Materials and Methods: This study was conducted on 370 male food handlers participating in public health training courses. Hygiene knowledge and attitude of subjects were evaluated at the beginning, 1 month, and 2 years after completion of public health training courses. Data were collected using self-designed questionnaire and checklist. Results: Knowledge scores of subjects improved from 20.55 ± 4.03 to 23.73 ± 3.75, attitude scores from 107.2 ± 14.6 to 112.2 ± 14.5, and practice scores from 43.93 ± 7.6 to 46.1 ± 3.75 resulting in 9.94%, 3.87%, and 4.66% improvement in food dealers’ knowledge, attitudes, and hygiene practices, respectively. Conclusion: The results showed that the educational intervention improved knowledge, attitude, and practice of preparation, distribution and sale food handlers, after a short period of training. Besides, after a long time, the knowledge and attitude level of participants are reduced and conversely, the level of practice has been increased.
Keywords: Attitude, food handlers, health training, knowledge, practice
|How to cite this article:
Pirsaheb M, Sharafi K, Moradi M, Fazlzadeh M, Adham D. Evaluation of short-term and long-term effect of health training courses on knowledge, attitude, and practice of food handlers. Ann Trop Med Public Health 2017;10:1649-55
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Pirsaheb M, Sharafi K, Moradi M, Fazlzadeh M, Adham D. Evaluation of short-term and long-term effect of health training courses on knowledge, attitude, and practice of food handlers. Ann Trop Med Public Health [serial online] 2017 [cited 2021 Apr 14];10:1649-55. Available from: https://www.atmph.org/text.asp?2017/10/6/1649/222690
Good personal hygiene and sanitary handling practices at work are an essential part of any prevention program for food safety. Although the majority of food handlers have the skills and knowledge to handle food safely, human handling errors have been implicated in most outbreaks of food poisoning., Public education is an important indicator for society development, and is in close relation with quality of life and economic, social, and cultural status. Health-related training improves learner’s knowledge, attitude, and skills toward healthy behavior changes., Food hygiene education has long been provided mainly by health authorities through public media to improve the safety of the food supply and minimize the occurrence of foodborne illness. Food safety remains a significant health concern in both developed and developing countries. It has been estimated that each year 1.8 million people die as a result of diarrheal diseases and most of these cases can be attributed to contaminated food or water. Foodborne diseases in the United States account for an estimated 48 million illnesses, 128,000 hospitalizations, and 3000 deaths annually., Proper food preparation and compliance with hygienic standards can reduce food contamination and prevent most foodborne diseases. Adequate protection of the consumer from foodborne illness can be achieved by inspection and training of food producers, manufacturers, distributors, and retailers.,, In most cases, the low level of knowledge and inadequate food practices are based on insufficient training of food handlers. Training of food handlers has been suggested as an important measure to provide food safety since 1990s. Improving hygiene knowledge of food handlers (involved in the preparation, production, and distribution of food) in small-scale enterprises play an important role in the promotion of food safety and quality of services provided and consequently prevents the outbreak of foodborne diseases., In practice, however, the enforcing hygiene standards on small-scale premises has been slow due to the vast number of the establishments scattered all over the cities.
Different studies showed that hygiene instruction can promote knowledge, attitude, and hygienic practices of workers dealing with food preparation and distribution in food establishments.,,,,,,,,,, Banaiy and Amini  assessed effect of public health training course on knowledge and hygienic practice of food retailers and found that hygienic knowledge of participants decreased by increasing their age and work experience. However, formal education level also positively related to their knowledge. Other study showed that knowledge, attitude, and practice scores of food dealers increased after training.
Clayton and Griffith  suggested that to design effective training for food handlers, there is a need to fully understand all the factors underlying food hygiene behavior in the workplace. A report published by the European Food Safety Authority (EFSA) shows that, in 2006, 22 member states reported 5710 foodborne outbreaks involving a total of 53,568 people, resulting in 5525 hospitalizations (10.3% of all the people involved) and 50 deaths (0.1%) In 2008, 25 member states reported 5332 foodborne outbreaks involving 45,622 people, resulting in 6230 hospitalizations and 32 deaths (EFSA). Jevsnik et al. found that approximately 50% of Hazard analysis critical control points implementation barriers related to training, human resources, planning, knowledge, competencies, and the management’s commitment to food safety. The inappropriate handling of foods by the food service industry has been implicated in 97% of food poisoning cases.
Iranian Health ministry has passed a regulation to mandate public health training course for all food dealers including workers and owners of food premises since 2001. Evaluation of knowledge, attitude, and hygienic practice of food handlers provides basic data for environmental health authorities to determine instructions quality given by authorized institutions. Therefore, this study conducted to investigate short-term (after a month) and long-term (after 2 years) effect of public health training courses on knowledge, attitude, and practice of managers and food handlers in Kermanshah city.
|Materials and Methods|
This semi-experimental study was conducted on 370 male food handlers participating in public health training courses (40 h) in Kermanshah city, Iran. Hygiene knowledge and attitude of subjects were evaluated at the beginning, 1 month, and 2 years after completion of public health training courses from 2009 to 2011. Of 370 subjects, only 253 food handlers participated in the last stage of the study. Subjects were divided into 3 categories based on the nature of their occupations; grocery and dairy, restaurant and confectionery, and bakery.
Data were collected using self-designed questionnaire and checklist. The questionnaire includes 32 (4 choices) and 29 (5 choices) questions to determine subjects’ hygiene knowledge and attitude, respectively. For knowledge questions, respective score of 0 and 1 were assigned for true and false answers. However, the attitude of participants were evaluated using Likert scale and scores of 1, 2, 3, 4, and 5 were assigned for “strongly disagree”, “disagree,” “neither agree nor disagree,” “agree,” and “strongly agree” options, respectively.
The hygienic practice of participants in the field of personal, utensils, and food hygiene as well as the physical conditions of food establishments (building sanitary) was evaluated using a checklist based mainly on the national regulations passed for food establishments by Iranian health ministry. The validity of the questionnaire was determined through review by environmental health senior experts and reliability was tested using Cronbach’s alpha analysis.
Descriptive statistics used for presenting data and analytical statistics (e.g., t test, analysis of variance, and Chi-square) were applied for comparison of knowledge, attitude, and practice of participants using SPSS version 16 software(SPSS Inc., Chicago, USA).
The average age of 370 participants in pretest and short-term posttest (1 month after training course) was 34.16 ± 13.04 (15–76) and 253 individuals participating in long-term posttest (2 years after training course) was 37.43 ± 12.82 years (17–76). Respective average job experiences for these groups were 9.14 ± 9.8 (0–60) and 12.04 ± 9.94 years (2–50).
Average scores for knowledge, attitudes, and hygiene practices for pretest and short-term posttest are presented in [Table 1]. Knowledge scores of subjects improved from 20.55 ± 4.03 to 23.73 ± 3.75, attitude scores from 107.2 ± 14.6 to 112.2 ± 14.5, and practice scores from 43.93 ± 7.6 to 46.1 ± 3.75 resulting in 9.94%, 3.87%, and 4.66% improvement in food dealers’ knowledge, attitudes, and hygiene practices, respectively (P < 0.001).
|Table 1: Comparison of average score of knowledge, attitude and practice in terms of the variables of age, education, work experience and job type (before and after training)
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Comparing scores between short-term and long-term posttests [Table 2] revealed that average score of knowledge decreased from 23.7 ± 3.8 to 21.9 ± 3.5 (P < 0.001) and attitude score from 112.2 ± 14.5 to 75.6 ± 6.6 (P < 0.001). However, practice scores increased from 46.1 ± 8 to 52.5 ± 6.6 (P < 0.001). Other results are presented in [Table 1] and [Table 2].
|Table 2: Comparison of average score of knowledge, attitude and practice in terms of the variables of age, education, work experience and job type (primary and secondary posttraining)
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Comparing to pretest results, short-term evaluation revealed improvement on average scores of knowledge, attitude, and practice of food handlers by 9.94%, 3.87%, and 4.66%, respectively. However, these are not satisfying considering cost and time devoted to such training courses. Since Iranian Health Ministry legislations have made compulsory the public health training certificate for food handlers, we strongly recommend a review on training items and instruction methods as well as the strict supervision on attendance of the participants in the courses. Lilian et al., Karimi et al. and Ahramposh et al. have indicated the effect of hygiene training on knowledge, attitudes, and practices of food handlers, but have not determined the extent of this effect. Kadivar  study also showed that overall condition of the food preparation, distribution, and sale centers had increased 16.9% after training.
Although the results of this study indicate the effect of time and training on knowledge, attitude and practice of all trade groups, (after 1 month of training courses), but the average scores of knowledge and attitude before training and after primary and secondary posttraining, in terms of trade grouping, showed no significant difference; however, average knowledge score in the secondary posttraining showed significant difference in the trade groups (P < 0.05). Therefore, the trade grouping has no effect on attitude level improvement but plays an important role in promoting of knowledge level, and different classes can be taught in a class regardless of any grouping. Comparing practice average scores before and after training also according to the job type variable shows reverse results and indicates the different job groups before training have different functions that these differences remain even after training. In addition, comparison of practice average score after the primary and secondary posttraining, in terms of the trade grouping shows that the different trade groups have had different practices after the primary and secondary posttraining. Therefore, it is recommended that different participants in terms of job type should be taught in separate classes so that the content of educational classes for each of them be different. Although, Karimi et al. study shows the impact of education on knowledge in all trade groups (dairy, sandwich shops, butchers, bakery, and confectionary), but its effect on attitude and practice level, according to the comparison of the pretraining and posttraining evaluation (short-term and long-term evaluation), has not been investigated.
In this study, the health education has been effective on knowledge, attitude, and practice of the study people in all age groups after 1 month of training courses. The significant difference in the knowledge, attitude, and practice average score before the training according to age grouping and also in the level of attitude and practice of handlers after the primary posttraining and the knowledge level after the secondary posttraining (P < 0.001) indicates the effect of age grouping on different levels of handlers education. On the other hand, the average score of knowledge and attitude of all participants in terms of age grouping is reduces after 2 years, but the practice of them increased after 2 years from primary posttraining. Therefore, the different of knowledge level before training and no different knowledge level after training showed the effect of education on knowledge of participants terms of age grouping, but the attitude and practice levels should be separated based on age groups of educational classes. The studies by Tang and Fang, Calin and Codrut, Giritlioglu et al., Karimi et al., and Radmehr et al. also show the effect of health education on knowledge in all age groups, regardless of its impact on the average scores before and after training.,,,,
The survey of the effect of health education on three levels of knowledge, attitude, and practice of the study groups in terms of the variable of work experience (after 1 month and 2 years of training courses) showed that passage of time has been effective in the training of all groups. The study results are in agreement with results obtained by Tang and Fang, Askarian et al., Calin and Codrut, Karimi et al. and Radmehr et al.,,,, The average score of knowledge and attitude of all participants, classified in terms of experience, has decreased after 2 years, but their practice has increased after this time. No significant differences in knowledge and attitude level before the education and in the knowledge level after the primary and secondary posttraining in terms of work experience grouping indicates no impact of experience on the knowledge and attitude of participants of training classes. On the other hand, significant difference of work experience grouping in practice level before training and in attitude and practice level after primary and secondary posttraining shows the reverse results. Regarding to the different behavior of participants grouped in terms of work experience before entering educational classes and its continuing after training (primary and secondary posttraining) in both attitude and practice level, and hence, the variable of work experience is one of the most important influencing variables on education of participants; hence, the participants with different backgrounds need to be educated in separate classes.
Studying the relationship between the impact of health education program on knowledge, attitude and practice of the participants in terms of education variable showed that the passage of time is effective in the training of all groups. This is in agreement with results obtained by Karimi et al. and Calin and Codrut., The significant differences in knowledge and attitude scores of participants pre- and posttraining in terms of grouping by education level reflects the effects of the education level of the learners participating in the courses and shows that the education level is one of the most important variables in this study. On the other hand, this course has no effect on homogenizing the knowledge and attitude level of participants in terms of education grouping. Comparing the average scores of the practice of participants before and after training also showed no effect of education grouping on the practice level of participants. Passing 2 years, caused reduce in the level of knowledge and attitude and increase in practice of all levels of education.
The differences in knowledge, attitude and practice of handlers, before and after training, based on the above-mentioned grouping variables, following the health training courses, showed that apart from trade grouping in the practice level, the special training course could has a significant effect on the knowledge, attitude, and practice of all groups related to each of these variables, although as it was stated earlier, to achieve the objectives of the course, the content, and its implement should change.
Many studies are conducted concerning the impact of health education on knowledge, attitude, and practice of food handlers,,,,,,,,,,, but the authors have not found any similar study concerning the effects of time on knowledge, attitude, and practice. What is important is that the passage of time has a significant impact on the practice of preparation, distribution and sale food staff, and after 2 years, the health-care practice of food handlers is better. Since, the health education is an especial course that leads to improvement of individual health behavior, and in other words, the ultimate aim of health education is changing behaviors and replacing health-care behaviors in society and bridging the gap between knowledge and practice, so as approved in this study, the practice of trade groups have been improved, and therefore it can be said that training given to the trade unions was drastically effective in health practice of handlers. Of course, control and inspection of environmental health experts and the necessity of comply with relevant instructions by handlers of food production and distribution centers, has had an important role in improving their practice.
Although, after the primary posttraining (after 1 month), the knowledge and attitude of participants have increased, the results of this study showed that in the secondary posttraining (after 2 years), the knowledge and attitude of participants has been reduced by passage of time. In fact, the passage of time has caused in reduced health information, even the attitude of the handlers. Therefore, it is required that special training courses be repeated at least after 2 years of primary posttraining. Health training courses need to be held as the transmission of health knowledge and attitude concepts be in correspondence with the knowledge level of participants and hence that the passage of time does not cause to forget the received information or a change in their attitude.
Results of the present study showed that average scores of knowledge, attitude, and practice have changed 2 years after the educational intervention. On other words, passing of time affected the knowledge, attitude, and practice of educated handlers. Passage of time has caused the average scores of knowledge fall from 23.7 ± 3.75 to 21.9 ± 3.5 as well as the attitude scores that fall from 112.2 ± 14.55 to 75.6 ± 6.6 (P < 0.001), but the scores of practice be increased from 46.1 ± 8 to 52.5 ± 6.6 (P < 0.001).
Therefore, the results showed that the educational intervention improved knowledge, attitude and practice of preparation, distribution and sale food handlers, after a short period of training; however, to increase the knowledge, attitude, and practice level of these handlers, the educational content and implementation methods of these courses should be revised. Training of the groups should be based on the trade groups, and be implemented as homogeneous, and to grant the certification of special training courses for trade unions, preparation of examinations and obtaining the minimum score seems to be required. Stabilizing the process through the follow-up actions and completing the knowledge and attitude questionnaires, as well as practice checklists after at least 2 years from the completion of this research is recommended. Implementation of retraining and apprenticeship training courses for handlers who passed the special courses of health, based on the results of this study, is necessary. Besides, after a time, the knowledge and attitude level of participants are reduced and conversely, the level of practice has been increased. The decrease in the knowledge and attitude level of participants should be compensated with repeated courses of health training. The increase in the practice level of the participants, regarding the decrease in the knowledge and attitude level of them after 2 years, may because of other causes other than the targeted training, which makes it necessary to provide a modern educational curriculum proportional to the knowledge level of participants in all educational levels, and so repenting the training in each level every 2 years after the primary courses is recommended.
One of the limitations of this study was the presence of participants from different professions in different classes with different ages and education levels; we tried to represent simple education contents. Furthermore, due to changing occupation, movements and death of some staff, the number of participants in the initial test (n = 370) was reduced to 253 in the second test.
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Conflicts of interest
There are no conflicts of interest.
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Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]