A comparison of traditional handwashing training with active handwashing training in the food handler industry.

Introduction

It is difficult to know the number of cases and the true cost of foodborne disease (Bean & Griffin, 1990a). The Centers for Disease Control and Prevention (CDC) recognize that literally millions of people are affected by foodborne disease each year and that the economic impact may be $5 billion or more (Altekruse & Swerdlow, 1996). To better characterize, understand, and respond to foodborne diseases, CDC created the Foodborne Diseases Active Surveillance Network (FoodNet) and has been tracking laboratory-confirmed cases of Campylobacter, Escherichia coli O157:H7, Listeria, Salmonella, Shigella, Vibrio, and Yersinia since 1996 (CDC, 1990; 1998).

In a 14-year CDC study that analyzed contributing factors for foodborne diseases, poor personal hygiene was the contributing factor most frequently reported in Shigella (91 percent), hepatitis A (96 percent), Norwalk virus (78 percent), and Giardia (100 percent) outbreaks (Bean & Griffin, 1990a). Personal hygiene also has been identified as the third most commonly reported food-preparation practice contributing to foodborne disease (Bean & Griffin, 1990b). CDC has stated that contaminated hands may be the most important means by which enteric viruses are transmitted (CDC, 1990).

According to Paulson, "The most effective way to break the contamination vector between foodhandling/processing personnel and consumers is for foodhandlers to perform an effective handwash using an effective hand cleanser" (1994). What is effective handwashing for food handlers?

The 1993 Food and Drug Administration (FDA) Food Code provides a standardized handwashing protocol which trainers can use to teach consistent handwashing technique (FDA, 1993). Details of the 1993 Food Code handwashing guidelines include the appropriate length of the wash, the appropriate use of the nailbrush, and determination of the appropriate procedure for a given situation (single or double handwashing).

Standard food handler handwashing training is often provided in a passive lecture and video presentation, the effectiveness of which may be marginal (Luskin, Somers, Woodling, & Levenstein, 1992). In standard lecture/video training, the instructor must rely on verbal or written checks of student understanding. An additional problem inherent in passive training is a potential language barrier since nonnative English speakers may not understand significant information (Wallerstein, 1992). A more effective way to achieve objectives for behavioral-skill development is to provide the learners with opportunities to observe demonstrations of behaviors and then to have "hands-on" practice in class or at the job site (Wallerstein & Weinger, 1992). Active training sessions afford instructors the opportunity to appropriately modify actual participant performance (Wallerstein & Weinger). As Paulson and co-authors observe, "Designing an accurate and valid method of determining the effectiveness of hand-cleansing regimens for food handlers is vital" (Paulson et al., 1999).

The study reported here was performed to evaluate the effectiveness of training food handlers in proper handwashing techniques. It compared conventional (lecture/video) training procedures with active ("hands-on" practice) training. The study included a two-week follow-up evaluation in an effort to assess the retention of important information and concepts.

Materials and Methods

The Salt Lake City (Utah) Health Department requires all food handlers to attend a one-and-one-half-hour food-handler-training course. The food handler course presents information on a number of different topics, including personal hygiene. Each participant must take a written exam at the completion of training. Successful performance on the exam is required to receive the certification necessary to work.

To evaluate food handlers' accurate retention of the FDA handwashing protocol, a 20-item multiple-choice test was created. The study assumed that the 1993 FDA Food Code handwashing guidelines were appropriate and effective. Five questions were designed to determine students' knowledge of handwashing procedure with respect to length of wash, areas of focus, and appropriate nailbrush use. Thirteen questions were designed to determine whether the food handler understood which situations required a single handwashing and which required a double handwashing. The final two questions were designed to determine attitudes:

* First, how likely were food handlers to increase their handwashing as a result of the training? and

* Second, which of the training methods did each food handler find the most informative?

Sixty-six food handlers attending the sponsored food handler courses volunteered to participate in the investigation. Demographic information was obtained for each subject regarding age, sex, education level, years of experience in the food industry, and number of times they had attended a food handler training course. Participants were randomly assigned into one of three groups. All participants received the same lecture/video training component. One group received the "hands-on" participatory training as well. The testing scheme used three groups of participants.

Group I These participants took the 20-item test before the training course began. They were the control group. The purpose of the control group was to establish what the background levels of knowledge were prior to training.

Group II These participants took the 20-item test after completion of the standard training course. When compared against Group I, Group II established the effectiveness of conventional (lecture/video only) training procedures.

Group III These participants took the 20-item test after completion of the standard training course with the addition of a participatory handwashing training activity.

The active training consisted of participants observing the instructor performing an FDA handwashing demonstration, followed by the participants performing the FDA handwashing procedure under the supervision of the instructor. The instructor's handwashing demonstration lasted approximately five minutes. There were two sinks present, so two participants performed the FDA handwashing procedure simultaneously. Typically six participants could complete the handwashing procedure within 10 minutes

When compared with Group I and Group II, Group III established the effectiveness of any additional learning provided by active training.

Two weeks after the in-class tests were given, approximately 25 to 30 percent of each group was randomly chosen for retesting. The same instructor administered the identical 20-item multiple-choice test over the phone. This follow-up step was performed in an effort to evaluate retention two weeks after training.

Results

Data were analyzed with ONEWAY Analysis of Variance (ANOVA) and the Pearson's Chisquare test. Demographic data for the 66 participants are presented in Table 1. Analysis revealed that there was no bias in the demographics of the three test groups.

Scores from the test given on the day of training are presented in Table 2. Results demonstrated significant differences in the performances of all three groups (df[2,63] = 57.34, p < .05). A Tukey's HSD procedure was performed, with a significance level of <.05 (Table 2).

Results from the identical 20-item test given by phone approximately two weeks after the initial training are presented in Table 3. Results demonstrate a significant difference between Group III and Group II as well as between Group III and Group I. No significant difference was found between Group I and Group II (df[2,15] = 9.28, p < .051). A Tukey's HSD procedure was performed, with a significance level of <.05.

Questions 19 and 20 from the test given on the day of training were analyzed to address the food handlers' attitudes. (Responses from Group I were not assessed since those participants took the test before they received the training.) Question 19 assessed how they believed their handwashing would change after the training. Results from Group II and Group III are presented in Table 4.

Question 20 assessed which part of the training participants had found most informative. Again, responses from Group I were not analyzed since those participants had taken the test before the training. Group II participants were asked to choose between the video, the lecture, and written testing. Group III participants received participatory handwashing training and were given four options to choose from in Question 20: the video, the lecture, written testing, and the handwashing practice. Results for Question 20 are presented in Table 5.

Discussion

Participants who received active handwashing training (incorporation of actual handwashing), demonstrated higher retention of the 1993 FDA Food Code handwashing protocol when compared with participants receiving passive (lecture/video) training.

Since at the time of this study, the state was just in the process of adopting the 1993 Food Code, it is unlikely that the food handlers were familiar with the handwashing protocol. Without training, mean scores were low. The mean score before any training was only 8 correct, indicating that food handlers were not able to "guess" the FDA procedure. Thus, training appears to be necessary for food handlers to understand and perform Food Code handwashing procedures correctly.

The identical 20-item test was administered by phone two weeks after the food handler training courses. Results indicate that "hands-on" training received by Group III was superior for two-week retention and that "hands-on" training produced significantly better results. The lack of statistical difference between Group I and Group II indicates that neither prenor post-testing is a superior teaching tool for two-week retention.

Results from Test Question 19 indicated that the participatory training would improve handwashing behaviors more than the nonparticipatory training. Responses to Test Question 20 indicated that almost 50 percent of the food handlers in the "hands-on" group found the handwashing practice the most informative aspect of the handwashing portion of class.

Conclusion

The study reported here used a 20-item exam to evaluate the effectiveness of different training methods for instructing food handlers on the 1993 FDA Food Code handwashing guidelines. While written performance does not necessarily indicate how food handlers will perform on the job, it does indicate whether they know the correct protocol. The results of the study suggest that it would be beneficial for food handler trainers to incorporate actual handwashing practice in their courses. The test performance on the day of training and the two-week retention for those who received handwashing practice as a component of training were higher than for the groups that did not receive "hands-on" training. The time and cost investments for incorporating this handwashing activity were minimal. The trainer's handwashing demonstration required approximately five minutes. Participant practice required approximately two minutes each. If sinks exist at the training facility, then the financial cost also is minimal: nailbrushes, towels, soap, and water.

TABLE 1 Demographics of Participants Who Responded

                                                           Number of
                                                           Participants

Age                         18-58 years old
Gender                      Male                           11
                            Female                         51
Education level             <12th grade                     8
                            High school graduate/GED       21
                            Some college                   19
                            College degree                 15
Number of classes attended  1st                            43
                            2nd                            11
                            3rd                             5
                            [greater than or equal to]4th   3
Months of employment as     6                              30
a food handler              7-12                            4
                            13-36                           3
                            >36                            22

TABLE 2 Descriptive Statistics: Test Results on the Day of Training

                                                              95%
              Number of     Mean Test  Test Score  Standard   Confidence
Group         Participants  Score      Range       Deviation  Interval

Group I*          22          8.0        1-13       3.2        6.6-9.4
Group II**        22         12.4        5-15       2.3       11.4-13.4
Group III***      22         15.8       13-18       1.3       15.2-16.4

* Test administered prior to training.
** Test administered following standard training.
*** Test administered following standard training and participatory
handwashing training.

TABLE 3 Descriptive Statistics: Test Results from Testing Two Weeks
After Training

                                                              95%
              Number of     Mean Test  Test Score  Standard   Confidence
Group         Participants  Score      Range       Deviation  Interval

Group I*          5           10.0        6-14       3.1        6.2-13.8
Group II**        6           11.2        9-13       1.7        9.4-13.0
Group III***      7           15.0       12-17       1.6       13.5-16.5

* Test administered prior to training.
** Test administered following standard training.
*** Test administered following standard training and participatory
handwashing training.

TABLE 4 Tabulated Results (Percentages) for Question 19, Obtained on the
Day of Training

Attitude                                    Group II  Group III

Would wash their hands the same as before      22         14
Would wash their hands a little more often     39         43
Would wash their hands a lot more often        39         43

TABLE 5 Tabulated Results for Question 20, Obtained on the Day of
Training

Preference                     Group II  Group III

Preferred video training          38         19
Preferred lecture training        52         33
Preferred written testing         10          0
Preferred "hands-on" training     N/A        47

REFERENCES

Altekruse, S.F. & Swerdlow, D.L. (1996). The changing epidemiology of foodborne diseases. American Journal of Medical Sciences, 311(1), 23-28.

Bean, N.H., & Griffin, P.M. (1990a). Foodborne disease outbreaks in the United States, 1973-1987: Pathogens, vehicles, and trends. Journal of Food Protection, 53(8), 804-816.

Bean, N.H., & Griffin, P.M. (1990b), Foodborne disease outbreaks, 5-Year Summary, 1983-1987. Journal of Food Protection, 53(8), 711-728.

Centers for Disease Control and Prevention. (1990). Viral agents of gastroenteritis public health importance and outbreak management. Morbidity and Mortality Weekly Report, 39(RR-5), 1-24.

Centers for Disease Control and Prevention. (1998). Incidence of foodborne illness: FoodNet 1997. Morbidity and Mortality Weekly Report, 47(37), 782-787.

Food and Drug Administration. (1993). Recommendations of the United States Public Health Service, Food and Drug Administration: Food Code (National Technical Information Service Publication PB94-113941). Washington, DC: Government Printing Office.

Luskin, J., Somers, C., Woodling, J., & Levenstein, C. (1992). Teaching health and safety: problems and possibilities for learner-centered training. American Journal of Industrial Medicine, 22, 665-676.

Paulson, D.S. (1994). A comparative evaluation of different hand cleansers. Dairy, Food and Environmental Sanitation, 14(9), 524-528.

Paulson, D.S., Riccardi, C., Beausoleil, C.M., Fendler, E.J., Dolan, M.J., Dunkerton, L.V., & Williams, R.A. (1999). Efficacy evaluation of four hand cleansing regimens for food handlers. Dairy, Food, and Environmental Sanitation, 19(10), 680-684.

Wallerstein, N. (1992). Health and safety education with low-literacy or limited-English skills. American Journal of Industrial Medicine, 22, 751-765.

Wallerstein, N. & Weinger, M. (1992). Health and safety education for worker empowerment. American Journal of industrial Medicine, 22, 619-635.

Dean R. Lillquist, Ph.D., M.P.H., C.I.H.

Mary L. McCabe, M.S.P.H.

Kurt Haden Church

Corresponding Author: Dean R. Lillquist, Associate Professor, University of Utah, Rocky Mountain Center for Occupational and Environmental Health, 391 Chipeta Way, Suite C, Salt Lake City, UT 84108. E-mail: [e-mail].