Knowledge and practices of food hygiene among food handlers in plantation sector, Sri Lanka

INTRODUCTION

An adequate wholesome food is essential to human beings for their existence.¹ However, food borne illnesses spread throughout the world due to consumption of contaminated food and therefore, be considered as a major health problem in worldwide and a significant cause of economic loss.² Food handlers play a vital role in ensuring food safety throughout the procedure of food preparation. It was estimated that millions of people become ill each year and thousands of them die after consuming contaminated foods due to poor food handling and safety methods of food handlers.³

Improper food handling, preparation and storage can result food contamination leading to food poisoning and food related diseases caused by intestinal parasites and pathogenic bacteria.⁴ Involving infected people in food processing increases the risk of food contamination via fingers due to most microorganisms can survive underneath of fingernails.⁵ Consumption of contaminated food is a major reason for more than half of diarrheal diseases in developing countries.⁶ Therefore, knowledge and attitudes of food handlers’ and hygiene practices directly affect food safety and hygiene in food establishments.⁷

Poverty, poor sanitary and food handling practices, lack of education and communicable diseases are prominent among food handlers in plantation sector in Sri Lanka. Very little information about food hygiene practices in plantation sector is available due to low number of studies has been conducted to assess food handling practices among adult population in the tea plantation sector of Sri Lanka. Therefore, the purpose of this study was to determine the practice and knowledge of food hygiene practices of food handlers in the plantation sector in Kandy district and made appropriate recommendations for the improvement of food safety and sanitary conditions.

METHODS

Study design and population

A cross-sectional descriptive study was conducted in tea plantations close to Hantane mountain range in Kandy district, Sri Lanka from July to September 2013. These study areas are one of the largest plantation areas in Kandy district and highly populated compare to other plantation areas. It is situated about 5 km away from Kandy and 120 km East from Colombo, the capital city of Sri Lanka. The educational status of adult population was poor people and lives with low sanitary and household facilities within very limited space. Streams and unprotected wells are main resources for drinking and other water requirements in this community. More than half of people have no latrine facilities and most of residents tend to go around bushy and forest areas for defecation. Most of food handlers are women in household level as most of men occupied outside from homes. In the present study all food handlers working in household level in this plantation area were used as the source of population. The sample size was calculated using a formula of n = z²pq/d². It was estimated that 50% of food handlers had a good knowledge of food hygiene and safety due to lack of previous similar studies in Sri Lanka. 5% marginal error, 95% confidence interval was also taken to calculate the sample size. The calculated minimum sample size was 384. Then out of total food handlers, 384 were selected by simple random sampling method for the study.

Collection of data

Before the commencement of the study, small group meetings were organized to explain the purposes of this study to all the selected food handlers with the help of regional health officers and written consents were obtained from each of the participants. An interviewer administrated structured questionnaire was used to collect socio-demographic characteristics, food handling practices, knowledge and attitudes of food safety and hygiene. Medical treatments were assessed by examining their medical reports and the awareness of food borne diseases was determined by the knowledge of transmission and symptoms of food borne diseases.

Questionnaire was basically prepared in English and was translated to their native languages (Sinhala and Tamil) to get more reliable information from respondents.

Practice of food safety and hygiene

There were 9 questions based on the practice of food safety and hygiene of food handlers. A three - point score scale was used for the analysis of responses (3 points for always, 2 points for some times, 1 for never). A total of 27 maximum achievable points was used for practice of food hygiene among study subjects. A score of 0-15 marks out of maximum marks was graded as poor practice while a score of 16-27 marks (≥60%) was graded as good practice.

Statistical analysis

Data entered into Microsoft Excel sheet and then were transferred into the statistical package for social sciences (SPSS) version 20 for statistical analysis. Descriptive statistics were used including percentage, mean and standard deviation to describe the analyzed variables in this community. Chi square test was used to determine relationship between socio demographic characteristics, medication and the knowledge of food hygiene with the practice of food safety and hygiene among study subjects. A 95% confidence level was used and P <0.05 was considered statistically significant.

Ethical consideration

Ethical approval was obtained from the ethical clearance committee, Faculty of Allied Health Sciences, University of Peradeniya, Sri Lanka. Written permission was also obtained from the administrations and health authorities of relevant tea plantations to conduct the study. Written consents were obtained from each participant before recruiting them to the study. All information provided by the respondents was kept confidential and analyzed only for research purpose.

RESULTS

Socio-demographic factors

A total of 375 food handlers in tea plantation areas (97.7% response rate) with the mean age were 33.4 ± 7.2 years participated for the study. The age range of the respondent was 18 - 63 years and the majority of them were females. Out of all respondents, 71% had completed only primary education and 13% had no any formal education. Most of the study subjects were unemployed, more than 5 years food handing experience and had low household income as shown in Table 1.

Food handling practices

Table 2 shows food hygiene practices of the participants. More than half of respondents never used proper hand washing techniques with soap and water during the time of food preparing. However, majority of subjects engaged in hand wash with soap and water after defecation. 54% of individuals’ cleaned food preparing equipment with disinfectants every time while 28% cleaned the workplace every time where food prepared.

Small number of subjects had the habits of trimming their fingers at regular interval, using aprons while food preparing and covering food protecting from rodents. In addition majority of food handlers do not use proper waste disposal system and proper cleaning method for raw vegetables before consuming. According to the criteria mentioned above in methodology part, 223 (59.5%) of studied food handlers were found to have good practice of food safety and hygiene. Gender of the respondents showed statistically significant relationship with practice of food safety and hygiene (p < 0.05). Similarly level of education of the food vendors, had statistical significant influence on the practice of food safety and hygiene as given in Table 3.

In Table 4 shows only small amount of food handlers in this community undergo regular medical checkup and taking anthelminthic drugs for deworming. Most of subjects stated that they have involved food preparing process while they were in ill conditions. However, more than half of respondents provided medications when they were ill. Majority of them showed good food hygiene habits and all of these four factors were statistically significant with food hygiene practices.

Knowledge of food hygiene and practice

The majority of food handlers had good knowledge of transmission and symptoms of food borne diseases and also most of food handlers believed that personal hygiene prevents food borne disease. In addition, most of them expressed that they believed microbes and rodents mainly cause to spread food borne diseases as in Table 5.

DISCUSSION

Food handlers in this study were in 18-63 age range and most of them were in 27-36 age group. Similar findings were reported in Nigeria, Slovenia and Malaysia indicating that majority of them was middle aged people less than 50 years.^8-10 In the present study, we found that majority of the respondents completed only primary education and 12.8% had no any formal education. This is not surprising because most of food handlers in this society were females. According to Demographic and health survey in 2006, 19.9% of female household population had no formal education while 39.2% completed only primary school education in the plantation sector in Sri Lanka.¹¹ They may be less knowledgeable about proper food hygiene and also about the transmission and spread of food borne diseases. Similar findings were documented in Ethiopia that high number of female food handlers had low educational background.¹² In the present study, level of education of study subjects significantly associated with their food hygiene practices. This is similar to some reports in India and Bangladesh identified that educational status of food handlers affect their food handling practices.^13,14 Most of food handlers had an experience of more than 5 years in this study. This is the result of more women involve food processing activities from their teenage life in this community. However, gender was found to be significant factor for food practices of the subjects. Knowledge of food hygiene among female is higher than men in this community because female concern more about health in their family members.

In the present study, 59.6% of the food handlers had good knowledge of food hygiene and safety which is similar to report of Malaysia (54.7) and in Nigeria (56.3%).^10,15 However, this is in contrast with results of a Thailand which was found 15.2% of food handlers had good food hygiene practices.¹⁶ Pathogenic organisms from infected food handlers can be transmitted to food via fecally contaminated hands, infected skin lesions, naso-pharyngeal secretions or fomites. Poor hand hygiene practices have been identified as a major source for foodborne outbreaks worldwide.¹⁷ Proper hand washing with soap can remove transient micro flora from the hands and prevent gastrointestinal infections.¹⁸ In the present study, majority of respondents had no practices of wash hands with soap and water while food handling process. Similar results have been reported in Nigeria which was only 21% of subjects had a practice of proper hand washing with soap and water. Although hand washing only with water can reduce the burden of normal flora, it cannot remove all type of pathogenic micro-organisms. Therefore, improper hand washing could be a major reason for high prevalence of food borne diseases present in the plantation sector. However, 88% of them confirmed that they wash hands with soap after defecation. This prevents the contamination of fecal microorganisms with fingers of food handlers after using latrines. During the period of food preparing, hands should be dried due to moisture facilitates the transfer of pathogenic organisms.¹⁹ However, majority of subjects expressed that they do not consider about the moisture of their hands while food preparing and serving.

Small number of food handlers had a habit of cleaning and sanitizing of food cutting surfaces every time. This is in contrast with a study in Trinidad, 45% of the food handlers cleaned and sanitized their cutting boards.²⁰ Studies in Nigeria and Kenya showed that unclean equipment and work premises affect food handling practices.^4,21 Therefore, proper cleaning of food preparing places and utensils are more important factors to reduce the spread of food borne diseases.

In this study, we found that very low proportion of the respondents had well-trimmed fingernails. Several pathogenic micro-organisms such as Campylobacter, E. coli and Salmonella can survive beneath fingernails and therefore always fingernails should be kept clean and short to prevent the pathogens transmit to foods.^22,23 Hair also should be kept clean and tidy as it can be a source of cross contamination of pathogens. Low proportion of this community had a habit of wearing hair restraints and protective clothing while food preparing which is inconsistent with studies in Nigeria reported that low percentage of food handlers used hair protection methods.^24,25 Aprons prevent foods contact with our body and reduce the risk of cross contamination of foods. However, very little number of participants had a practice of wearing aprons while food preparing. Aprons should be clean and light colored. Wearing unclean aprons also increase the risk of transmits pathogenic organisms into food.

Eating raw vegetables have been identified as a source of outbreak of giardiasis.²⁶ Present study shows high number of food handlers have no a habit of cleaning raw foods with treated water. Poor food handling of infected people is a major risk of contamination of raw vegetables and fruits because no proper methods to control pathogens on raw vegetables before consuming. Purified water should be used for drinking purposes due to many types of pathogenic organisms can survive in untreated water. It was reported that chlorinated water can destroy Salmonellae.²⁷ There was no proper chlorinated water drainage system and the awareness programs of food security in the study area. Therefore majority of this community used untreated water to clean raw food. This could be another reason to increase the prevalence of infectious diseases in plantation sector.

Medical examination of food handlers is necessary to ensure that communicable diseases are not associated with food handlers. It is more important to decrease outbreaks of food borne diseases. Recent studies found that contamination of food handling causes 10% to 20% of food borne disease outbreaks worldwide. Present study shows only 8% of the food handlers had been undergone medically examination at regular pattern. Poor health care services and high cost of laboratory tests were major reasons to discourage people from medical screening at regular pattern. In addition, very low numbers of food handlers are getting anthelminthic drugs at regular interval. Several studies have been documented that high prevalence of intestinal parasitic infections present among children in the plantation sector of Sri Lanka.^28-30 Due to close relationship between children and their mothers, majority of women in this community may harbor intestinal parasites in their gastrointestinal tract. However when disease conditions expressed, most of correspondents take treatments as other communities do. Streptococci and Staphylococci are commonly transmitted via infected skin lesions on exposed body parts. In addition, aerosolisation has been identified as a mode of transmission of some vital outbreaks such as Norovirus.³¹ Therefore adequate covering of these infected lesions by colored waterproof dressings is important to ensure the reduction of cross contamination of foods. In addition, food handlers with purulent discharges should not contact with food because they also a potential source of food contamination.

In our study, majority of our study subjects were aware of food borne illnesses which is similar to results in Ethiopia and Nigeria.^15,32 The proper training of food handlers is a most effective process to reduce the risk of contamination of foods. The large proportion of food handlers expressed that they had never been trained on food handling and preparation. The lack of good food hygiene in the present study indicates that inadequate training of food handling principles may negatively affect to improve food hygiene and safety practices. However majority expressed that they got many knowledge about food hygiene practices and the awareness of food borne diseases from their elders, society and also from mass media. Although most of the respondents had an idea of good food hygiene practices can reduce the risk of food borne diseases they do not have a scientific knowledge of how those food practices contribute to reduce food related diseases.

CONCLUSION

40% of food handlers do not follow good food hygiene methods. Proper training of food hygiene practices promoting good personal hygiene and regular medications should be implemented to enhance the knowledge of food handing and food borne diseases among food handlers in the plantation sector, Sri Lanka.

ACKNOWLEDGEMENTS

The authors are very grateful to the academic staff and technical officers of Department of Parasitology, Faculty of Medicine, University of Peradeniya. Special thanks also go to the management of the estate, medical authorities, welfare officers and other health care workers from respective states for their technical assistance. Most importantly, the authors would like to express our deepest gratitude to all the food handlers who have voluntarily participated in this study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Ethical Review Committee, Faculty of Allied Health Sciences, University of Peradeniya, Sri Lanka

REFERENCES

1. 1. WHO. Establishing or Strengthening National food Contamination Monitoring Programs Guidelines, Geneva. World Health Organization. 1979.
2. 2. Stephenson LS, Latham MC, Ottesen EA. Malnutrition and parasitic helminth infections. Parasitol. 2002;121:23-38.
3. 3. Garden-Robinson J. A Reference Guide for Foodservice Operators. Food and Nutrition Specialist North Dakota State University, NDSU Extension Service, Food Safety Basics. 2012.
4. 4. Havelaar AH, Cawthorne A, Angulo F, Bellinger D, Corrigan T, Cravioto A, et al. WHO initiative to estimate the global burden of foodborne diseases. Lancet. 2013;381:59.
5. 5. Schlundt J, Toyofuku H, Jansen I, Herbst SA. Emerging food‑borne zoonoses. Rev Sci Tech. 2004;23:513‑33.
6. 6. Flint JA, Van Duynhoven YT, Angulo FJ, Delong SM. Estimating the Burden of Acute Gastroenteritis, Foodborne Disease and Pathogens Commonly transmitted by food. An international review. Clin Infect Dis. 2005;41:698-704.
7. 7. Okubagzhi G. Ova, larva and cyst in fingernail contents. Ethiop Med J. 1988;26:33‑6.
8. 8. Chukuezi OC. Food safe and hygiene practices of street food vendors in Owerri, Nigeria. Stud Soc Sci. 2010;1:50-7.
9. 9. Jevsnik M, Hlebec V, Raspor P. Food safety knowledge and practices among food handlers is Slovenia. Food Control. 2008;19:1107-18.
10. 10. Nee SO, Sani NA. Assessment of knowledge, attitude and practices among food handlers at residential colleges and canteen regarding food safety. Sains Malaysiana. 2011;40(4):403-10.
11. 11. Department of Census and Statistics in collaboration with Ministry of Health, Sri Lanka Demographic and Health Survey 2006/2007. Colombo, Sri Lanka. 2007.
12. 12. Tessama AG, Gelaye KA, Chercos DH. Factors affecting food handlers practices among food handlers of Dangila town food and drinks establishment in North West Ethiopia. BMC public Health. 2014;14:571.
13. 13. Mudey D, Goyal R, Dawale A, Wagh V. Health status and personal hygiene among food handlers working at food fstablishment around a rural teaching hospital in Wardha district of Maharashtra, India. Glob J Health Sci. 2010;2(2):198-206.
14. 14. Rabbi SE, Dey NC. Exploring the gap between hand washing knowledge and practices in Bangladesh: a cross-sectional comparative study. BMC Public Health. 2013;13:89.
15. 15. Afolaranmi TO, Hassan ZI, Bello DA, Misari Z. Knowledge and practice of food safety and hygiene among food vendors in primary schools in Jos, Plateau State, North Central Nigeria. J Med Res. 2015;4(2):16-22.
16. 16. Cuprasittrut T, Srisorrachatr S, Malai D. Food safety knowledge, attitude and practice of food handlers and microbiological and chemical food quality assessment of the food for making merit for Monks in Ratchathewi Distict, Bangkok. Asian J Public Health. 2011;2:27- 34.
17. 17. Bean NH, Griffin PM, Goulding JS, Ivey CB. Foodborne Disease Outbreaks, 5-year summary, 1983-1987. Morbidity and Mortality Weekly Report. 1990;39(1):15-57.
18. 18. Snyder OP. Hand washing for retail food operations – A review. Dairy Food Environ Sanit. 1998;18(3):149-62.
19. 19. Patrick DR, Findon G, Miller TE. Residual moisture determines the level of touch-contact-associated bacterial transfer following hand washing. Epidem Infect. 1997;119(3):319-25.
20. 20. Pattron DD. An observational study of the awareness of food safety practices in households in Trinidad. Int J food safety. 2006;8:14-8.
21. 21. Muinde O, Kuria E. Hygienic and sanitary practices of vendors of street foods in Nairobi, Kenya. Afr J Food Agri Nutri Develop. 2005;5(1):1-14.
22. 22. Lues JFR, Rasephei MR, Venter P, Theron MM. Assessing food safety and associated food handling practices in street food vending. Int J Environ Health Res. 2006;16:319–28.
23. 23. Ferron S, Morgan J, O’Reilly M. Hygiene Promotion: A Practical Manual for Relief and Development; Intermediate Technology. Warwickshire, England: Practical Action Publishing and care; 2000.
24. 24. Abdussalam M, Kaferstein FK. Safety of street foods. World Health Forum. 1993;14:191-4.
25. 25. Abdalla MA, Siham ES, Alian YYHA, Amel OB. Food safety knowledge and practices of street food-vendors in Khartoum city. Sudan J Vet Sci Animal Husb. 2008;47:126-36.
26. 26. Mintz ED, Hudson-Wragg M, Mshar P, Cartter ML, Hadler JL. Foodborne Giardiasis in corporate office setting. J infect Dis. 1993;167(1):250-3.
27. 27. Bryan FL. Risks of practices, procedures and processes that lead to outbreaks of food‑borne illness. J Food Protect. 1988;51:663‑73.
28. 28. Galgamuwa GLS, Iddawela WMDR, Dharmaratne SD. Development and Piloting of Ascariasis Surveillance System of Children in Sri Lanka. Online J Public Health Inform. 2015;7(1):130.
29. 29. Suraweera OSA, Galgamuwa LS, Iddawela D, Wickramasinghe S. Prevalence and associated factors of Enterobius vermicularis infection in children from a poor urban community in Sri Lanka: a cross-sectional study. Int J Res Med Sci. 2015;3(8):1994-9.
30. 30. Galgamuwa LS, Iddawela D, Dharmaratne SD. Intestinal protozoa infections, associated risk factors and clinical features among children in a low-income tea plantation community in Sri Lanka. Int J Community Med Public Health. 2016;3(9):2452-8.
31. 31. CDC. Updated norovirus outbreak management and disease prevention guidelines. Morbidity and Mortality Weekly Report. 2011;60:3.
32. 32. Zeru K, Kumie A. Sanitary conditions of food establishments in Mekelle town, Tigray, North Ethiopia. Ethiop J Health Dev. 2007;2(1):1-9.