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The personal and general hygiene practices of food handlers in the delicatessen sections of retail outlets in South Africa.

Introduction

The high incidence of foodborne illnesses has led to an increase in global concern about food safety. Several foodborne-disease outbreaks have been reported to have been associated with poor personal hygiene of people handling foodstuffs (Altekruse, Timbo, Mowbray, Bean, & Potter, 1998; Bryan, 1988; Parish, 1998; Shapiro et al., 1999; Vought & Tatini, 1998). Food handlers have a major responsibility in the prevention of contamination associated with food spoilage and food poisoning during the production and distribution of food and, if personal hygiene is unsatisfactory, they may cross-contaminate raw and processed foodstuffs or asymptomatic carriers of pathogenic organisms may contribute to the spread of disease (Walker, Pitchard, & Forsythe, 2003). Although significant advances have been made with respect to food safety, in many developing countries inadequate practices and surveillance systems persist, and there is often a risk of food being microbiologically hazardous to the consumer (Department of Health, South Africa, 2000a; Escartin, 1997). The socioeconomic impact of foodborne illness includes loss of productivity, loss of income, loss of trade, loss of food as a result of condemnations, and ultimately loss of tourism (Department of Health, South Africa, 2000b).

As a result of the internationalization of South African industry after the removal of sanctions, a growing awareness has developed about the importance of quality improvement to being competitive. Improvement is achieved through formalized disciplines such as the HACCP system and by replacing the traditional concepts of quality control with an emphasis on end-product monitoring (Mbendi, 2003). According to the South African Regulations related to the application of the HACCP system, no owner of a delicatessen (including a delicatessen on supermarket premises as per Annex A in the regulations) is allowed to handle food without a HACCP system being fully implemented to the satisfaction of the relevant authority (Republic of South Africa, 2003). The provision of food hygiene training for all food handlers should significantly reduce food contamination and, as a result, the incidence of foodborne diseases (Ehiri & Morris, 1996). Therefore, management should ensure that all staff are medically fit, adequately trained in both personal and food hygiene practices, and wearing clean, protective clothing when entering or working on the food premises (South African Bureau of Standards, 2001). Kitcher (1994) and Tebbutt (1992) identified correlations among management's attitude toward training, levels of hygiene knowledge, and standards of food-handling practice. Food hygiene training is therefore crucial in food safety and an essential part of the HACCP concept (Walker et al., 2003).

The aim of the study reported here was to cast light on the personal and general hygiene practices of food handlers in the delicatessen sections of a major retail group as well as to investigate their level of training in personal and general hygiene. There is a constant competition among outlets based on quality, safety, and wholesomeness, and the results of the study will be available to the management so that it can assess the need for further training.

Methods

Pilot Study

The questionnaire was piloted at one outlet, where it was administered to six food handlers who were not included in the actual test sample. The purpose of the pilot study was to assess the clarity of the questions and to determine time requirements, as it was important that the time required for completing the questionnaire was not perceived by retail outlet managers as disruptive to normal activities (Walker et al., 2003).

Interviewing Protocol

Interviews were conducted among a random selection of food handlers in the delicatessen sections of 35 outlets of a major retail group in the Western Cape, South Africa. The management of the retail group granted permission for interviews to be conducted with the food handlers in the delicatessen sections after a confidentiality agreement was signed. Fifty respondents were individually interviewed during working hours (weekdays between 10:00 and 14:00) without previous notification. To limit variation, the interviews were conducted by the same interviewer and care was taken to ensure consistency of approach in the conduct of the survey on each of the food premises and to minimize any influences or subsequent biases in results (Walker & Jones, 2002).

Questionnaire Design

The questionnaire was structured to obtain information about each food handler's training and knowledge of personal and general-process hygiene and consisted of 37 questions that included both closed and open-ended questions (Coggon, 1995). The aim of the survey was clearly stated on the questionnaire, and the confidentiality of the survey was emphasized to the respondents. Interviews were conducted in the languages predominantly used by the food handlers (Afrikaans and English), and the structured interview method, as described by Czaja and Blair (1996) and Katzenellenbogen, Joubert, and Karim (1997), was followed. This method was advantageous because 1) it had a well-defined structure that prevented the respondents from making their own interpretations, 2) it allowed respondents with low or no literacy levels to be interviewed, and 3) the interviewer could explain questions that were not clear to the respondent.

Data Analysis

The questionnaires were coded and analyzed in collaboration with the Department of Bio-statistics, University of the Free State (SAS/STAT, 1989). The results were presented in tables in the form of frequencies and percentages (Nel, Lues, Buys, & Venter, 2004).

Results

All the respondents interviewed in the study were full-time employees in the delicatessen sections of retail outlets. Responses on general questions revealed the age distribution of the workers (data not shown) as follows: 18 to 21 years (18 percent), 22 to 30 years (32 percent), 30 to 40 years (28 percent), and older than 40 years (22 percent). Educational qualifications ranged from 74 percent with less than a high-school senior certificate to 24 percent with a senior certificate to only 2 percent with a post-school qualification. With respect to experience, 2 percent had less than three months' work experience in the delicatessen section, 14 percent had more than 6 to 12 months' experience, and 84 percent had more than a year's experience.

Although only 72 percent of respondents reported that a handwashing facility with soap and air dryer or disposable hand-drying material were available in restrooms, all respondents indicated that they washed their hands before the commencement of each work shift, after a rest period, after having a smoke, or after visiting the toilet or handling money, refuse, or a refuse container (Table 1). Not all the respondents (49 of 50) said that they washed their hands every time they blew their nose or touched their hair, nose, or mouth, and 48 of 50 (96 percent) washed their hands after handling raw vegetables, fruit, eggs, meat, or fish or before handling ready-to-eat food. Forty-seven of the respondents (94 percent) washed their hands under all circumstances mentioned. With respect to the means of handwashing, 8 of 50 respondents (16 percent) used cold water, soap, and a nailbrush; 44 percent used hot water, soap, and a nailbrush; and 40 percent used hot and cold water and soap. Disposable hand-drying material was used by almost all of the respondents (98 percent), except for one, who admitted to sometimes using his or her apron or clothes for hand drying (Table 1).

Three of the 50 respondents (6 percent) kept their fingernails long, and 6 (12 percent) wore jewelery when at work (Table 2). When the respondents were asked whether they wore moisture-proof dressings after accidentally cutting themselves, four (8 percent) admitted to wearing dressings that were not moisture-proof. The wearing of protective clothing is also summarized in Table 2. Twelve of the respondents (24 percent) replaced their aprons two to five times a day, while two (4 percent) replaced their aprons more than five times a day. With respect to the frequency of glove replacement, four (8 percent) indicated that they replaced their gloves with clean ones two to five times a day, while the other 92 percent replaced their gloves more than five times a day. All 50 respondents discarded their gloves after removing them.

Inquiries about illness at work (data not shown), revealed that 46 of 50 (92 percent) never suffered from diarrhea, while 4 of 50 (8 percent) had diarrhea once per year; 47 of 50 (94 percent) never vomited, while 2 of 50 (4 percent) vomited once per year; 90 percent never had a fever, while 4 of 50 (8 percent) had fever once per year; and 37 of 50 (74 percent) never had a cough, while 7 of 50 (14 percent) had a cough once per year. Upon being asked whether they ever had a cold or flu while working, 26 of 50 (52 percent) indicated that they did so once per year, while 3 of 50 (6 percent) indicated that they never suffered from a cold or flu at work. Cut or bruised hands were experienced once per year by 9 of 50 (18 percent), two to five times per year by 9 of 50 (18 percent), and more than 10 times per year by 3 (6 percent) of the respondents, while 5 (10 percent) never experienced cut or bruised hands.

Table 3 shows that 45 of 50 (90 percent) of the respondents reported illness to management. Thirty-seven (82 percent) of the 45 respondents who indicated that they reported illness stated that management would arrange for a medical examination and that they would also receive sick leave. Only 7 percent of the respondents, however, reported that they took sick leave, and only two (4 percent) went for a medical examination. Although it was evident that cuts and burns are common in this food-handling practice, three respondents (7 percent) reported that no action was taken by management after injuries were reported. Forty-seven (94 percent) of the respondents who reported an injury to management indicated that they covered the wound with a moisture-proof dressing. The remaining 6 percent of the respondents did not bother to apply any of these precautions.

Respondents were asked about the prevalence of rats, mice, flies, or cockroaches in the food-handling areas (data not shown). Responses revealed that rats and mice were encountered as follows: never by 64 percent, daily by 4 percent, weekly by 6 percent, monthly by 10 percent, seasonally by 2 percent, and annually by 14 percent. Flies were encountered as follows: never by 24 percent, daily by 4 percent, and seasonally by 72 percent. Cockroaches were encountered as follows: never by 66 percent, daily by 10 percent, weekly by 2 percent, monthly by 16 percent, seasonally by 2 percent, and annually by 4 percent.

A formal cleaning schedule was not in place in all the outlets, as 8 percent of the respondents indicated that they "clean-as-they-go." As indicated in Table 4, one respondent reported that surfaces are only cleaned and washed after a day's work is finished, while another one stated that surfaces are cleaned and washed daily before start of work, daily after work is finished, and during or immediately after the handling of food or both. Two respondents (4 percent) reported that surfaces are cleaned and washed daily after work is finished, between shifts, and during or after the handling of food or both, while 92 percent reported that surfaces are cleaned under all the circumstances mentioned. Cold water and detergent were used as a means of cleaning/washing by 22 percent of the respondents, and 78 percent used hot water and detergent (Table 4).

Forty-two of the 50 respondents (84 percent) indicated that they had received for-mal training on aspects of personal hygiene, while 42 of 50 (84 percent) had received formal training in general hygiene. The majority of these food handlers had received their training either at head office (36-38 percent) by means of courses and videos, or locally by videos only (33-36 percent).

Discussion

The majority of foodborne-disease outbreaks result from faulty food-handling practices, and a study done in the United States has suggested that improper food-handling practices contribute to approximately 97 percent of foodborne illnesses in food service establishments and homes (Clayton, Griffith, Price, & Peters, 2002). Pathogens that are most commonly associated with inadequate hygienic practices are the enter-obacteriaceae, such as Escherichia coli and other coliforms, as well as members of the genera Salmonella, Shigella, Yersinia, Proteus, and Klebsiella (Nel et at., 2004). Effective handwashing is an essential control measure for prevention of pathogen transmission in food service establishments, and the health regulations under the Health Act stipulate that it is the responsibility of food handlers to wash their hands thoroughly with soap and water under all relevant circumstances (Republic of South Africa, 1999). Facilities for personnel should be adequate, and all handwashing basins in toilet areas must be supplied with hot and cold water, and hand-cleaning preparations in dispensers and paper towels or air hand-dryers should be provided (Codex Alimentarius, 1997; Paulson et al., 1999; South African Bureau of Standards, 2001). The potential for cross-contamination is reduced, however, when disposable paper towels are used (Hobbs & Roberts, 1993).

Humans are often the source of disease-producing microorganisms, which occur as normal habitants in certain parts of the body, mainly the hair, nose, mouth, throat, bowels, and skin. These microorganisms are then readily transferred to the hands. Even blowing one's nose into a handkerchief can contaminate the hands, and food handlers should avoid direct contact with food when possible (Martinez-Tome, Vera, & Murcia, 2000; South African Bureau of Standards, 2001). Epidemiological studies show that one factor that often contributes to Staphylococcus food-poisoning outbreaks is the human carrier who handles foods in food service establishments (Martinez-To-me et al., 2000). According to the health regulations, food shall not be handled by any individual who has on his or her body a suppurating sore, cut, or abrasion, unless the wound is covered by a moisture-proof dressing that is firmly secured (Republic of South Africa, 1999). Any behavior that could result in the contamination of food, such as eating and chewing (of gum, sticks and sweets) should also be prevented in food-handling establishments (Republic of South Africa, 1999; South African Bureau of Standards, 2001). It is also essential, when unprotected food or raw food materials are handled, that personnel remove jewelery from their hands, while fingernails should be kept short and clean (Republic of South Africa, 1999; South African Bureau of Standards, 2001).

Employees suffering from disease symptoms such as fever, diarrhea, upset stomach, nausea, vomiting, sore throat, coughing, or sneezing--or even individuals suspected to be suffering from or to be carriers of a disease or illness that can readily be transmitted through food--should not be allowed to enter any food-handling area and should report illness or related symptoms to management (Codex Alimentarius, 1997; Lorenzini, 1995; Republic of South Africa, 1999; South African Bureau of Standards, 2001). During the acute stages of diseases such as gastroenteritis, large numbers of organisms are excreted and can be widely dispersed (Bannister, Begg, & Gillespie, 2000). Food handlers who are symptomatically ill, therefore, present a serious health hazard and should be excluded from work. Such individuals should furthermore be made aware of the need to immediately report illnesses and should be assured that if exclusion is necessary it will not result in loss of employment or wages. Medical examination of a food handler should be carried out if clinically or epidemiologically indicated (Codex Alimentarius, 1997), and a certificate by a medical practitioner should be submitted, stating whether such person is fit to handle food (Republic of South Africa, 1999).

Thoroughly clean food contact surfaces is critical to food safety and to prevent any form of contamination, a surface should be cleaned before any food comes into contact with it for the first time and, when necessary, during or immediately after the handling of food (Moore & Griffith, 2002; Republic of South Africa, 1999). Although incorrect cooking and storage of food is considered to be the main cause of foodborne infection, inadequate surface hygiene is a significant contributing factor, and the role of contaminated surfaces in transmission of pathogens to food is well known in food processing and catering (Cogan, Slader, Bloomfield, & Humphrey, 2002; Kusumaningrum, Riboldi, Hazelegger, & Beumer, 2002). By preventing food contamination, high standards of cleanness on food premises promote the maintenance of shelf-life as well as the protection of consumer health (Moore & Griffith, 2002). Therefore, it is stipulated in the health regulations that food premises must be equipped with a washing-up facility with hot and cold water for the effective cleaning of work areas (Republic of South Africa, 1999).

All the respondents wore plastic or material aprons, gloves, and hairnets. According to the health regulations (Republic of South Africa, 1999), no person shall be allowed to handle food without wearing suitable protective clothing. Such clothing should be 1) clean and neat before any food is handled, 2) in a clean condition at all times during the handling of food, 3) of such design and material that it would not contaminate the food, and 4) designed not to come into direct contact with any part of the food. Management is responsible for the cleaning and issuing of protective clothing and should ensure that it is not removed from the premises for cleaning or repair without authorization (South African Bureau of Standards, 2001). Although the use of gloves in the handling of food should be limited to cases in which workers' hands need to be protected against physical, chemical, or temperature harm, or where foodstuffs are to be protected from possible contamination by the worker (South African Bureau of Standards, 2001), it is stipulated in the health regulations that no food handler may touch ready-to-eat non pre-packed food with his or her bare hands unless doing so is unavoidable for preparation purposes (Republic of South Africa, 1999).

Education is just as important as legislation in approaching the reduction of foodborne disease outbreaks (Worsfold & Griffith, 1995). Training in food hygiene practices is, therefore, fundamentally important, and personnel should be aware of their role and responsibility in protecting food from contamination. All food handlers should be considered potential carriers of pathogenic microorganisms and should be adequately trained in good manufacturing practices (GMP) to ensure that they have the knowledge and skills necessary for handling food (Codex Alimentarius, 1997). Management should be obligated to arrange for all food handlers to receive adequate and continued training in the hygienic handling of food so that they know which precautions to take to preclude contamination of food (South African Bureau of Standards, 2001). Studies in the United Kingdom have shown that training increases the level of hygiene and that businesses with a higher percentage of trained staff had a lower risk of their products being hazardous to consumers (Powell, Atwell, & Massey, 1997). A study done by Tebbutt (1992) has furthermore confirmed that management's attitude is an important determinant in training standards. It was found that on premises where training programs had been implemented for staff working with high-risk foods, working practices and personal hygiene improved, while the risk of contamination decreased significantly. Emphasis should also be placed on continuous training, and it is incumbent on all food professionals to lead by example (Daniels, 1998). Consumer protection from foodborne illness is improved by the application of a systematic approach to the identification and evaluation of food safety hazards (the HACCP method) (Soriano, Rico, Molto, & Ma es, 2002). While formal training may ensure greater consistency and quality, however, improper training could present a higher risk to food safety than no training at all (Mortlock, Peters, & Griffith, 2000). Proper training of food handlers is one of the cornerstones of the HACCP program and should be part and parcel of an operation's basic employee training (Norton, 2002).

Conclusion

Results of the survey demonstrate room for improvement, especially with regard to the provision of proper cleaning facilities, personal practices when preparing food, and training. Although the majority of the food handlers indicated that they adhere to good personal and general hygiene practices, issues such as the wearing of jewelery, long fingernails, and wound dressings that are not moisture-proof, and the failure sometimes of management to take action when illnesses or injuries are reported, remain serious concerns. Cases in which illnesses were reported to management but in which no action was taken indicate a need for mandatory training for managers. It should also be the manager's task to foster employee commitment to personal and general hygiene. Managers should furthermore recognize the need for training within their own establishments and accordingly implement training for all levels of staff. In some outlets there is also a need for more adequate supervision. When supervision is not up to standard, it should be the task of the manager of the outlet to intervene and to ensure that staff conform to the requirements. The need for a formal cleaning schedule should be emphasized, and staff should be informed about their responsibilities and the importance of adhering to such a schedule. With the new regulations related to the application of the HACCP system, managers will increasingly be faced with new challenges if they are to comply with the above regulations. The continuous incidence of foodborne illnesses requires all food handlers and their managers to be acutely aware of their responsibilities to produce food that is not only high in quality, but also safe for consumption.

Acknowledgements: The authors wish to thank the National Research Foundation of South Africa for research funding.

Corresponding Author: M.M. Theron, Central University of Technology, Free State, Unit for Applied Food Science and Biotechnology, Faculty of Health and Environmental Sciences, Private Bag X20539, Bloemfontein 9300 South Africa. E-mail: mtheron@cut.ac.za.

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Although most of the information presented in the Journal refers to situations within the United States, environmental health and protection know no boundaries. The Journal periodically runs International Perspectives to ensure that issues relevant to our international constituency, representing over 60 countries worldwide, are addressed. Our goal is to raise diverse issues of interest to all our readers, irrespective of origin.

Izanne van Tonder, D.Tech.

Jan F.R. Lues, Ph.D.

Maria M. Theron, Ph.D.
TABLE 1 Handwashing Practices and Conditions Reported by Survey
Respondents

Practice or Condition Frequency (n = 50)

Handwashing facility with only cold water or 36 (72%)
 with both cold and hot water, and with soap,
 air dryer/disposable hand-drying material

Frequency of Handwashing
 Immediately prior to the commencement of 50 (100%)
 each work shift
 At the beginning of the day's work or 50 (100%)
 after a rest period
 After every visit to a latrine or urinal 50 (100%)
 Every time the nose is blown or hair, nose, 49 (98%)
 or mouth is touched
 After handling money, a refuse container, or 50 (100%)
 refuse
 After handling raw vegetables, fruit, eggs, meat, 48 (96%)
 or fish and before handling ready-to-use food
 After smoking or on return to the food premises 50 (100%)
 Under all the circumstances mentioned 47 (94%)

Means of Handwashing
 Cold water, soap, and a nailbrush 8 (16%)
 Hot water, soap, and a nailbrush 22 (44%)
 Hot and cold water and soap 20 (40%)

Means of Hand Drying
 Disposable hand-drying material 49 (98%)
 Apron/clothes 1 (2%)

TABLE 2 Food Preparation Practices Reported by Survey Respondents

 Frequency
Practice (n = 50)

Food Handling
 Work with long fingernails 3 (6%)
 Wear dressings that are not moisture-proof 4 (8%)
 Wear jewelery 6 (12%)
 Wear jewelery and dressings that are not moisture-proof 2 (4%)
 Chew gum and wear dressings that are not moisture-proof 1 (2%)
 None of the above 34 (68%)

Frequency of Apron Replacement
 Never 2 (4%)
 Once a day 16 (32%)
 Twice a day 18 (36%)
 Two to five times a day 12 (24%)
 More than five times a day 2 (4%)

Frequency of Glove Replacement
 Two to five times a day 4 (8%)
 More than five times a day 46 (92%)
 Discard after removal 50 (100%)

TABLE 3 Practices with Respect to Illness in the Workplace as Reported
by Survey Respondents

Practice Frequency

Reporting of Illness to Management (n = 50)
 Yes 45 (90%)
 No 5 (10%)

Action Taken by Management (n = 45)
 Medical examination and sick leave 37 (82%)
 Only sick leave 3 (7%)
 Only medical examination 2 (4%)
 No action by management 3 (7%)

Action Taken When Injured (n = 50)
 Report to management and cover with moisture-proof dressing 47 (94%)
 Other 3 (6%)

TABLE 4 Surface-Cleaning Practices Reported by Survey Respondents

 Frequency
Practice (n = 50)

Frequency
 Daily after work is finished 1 (2%)
 Daily after work is finished; between shifts; and during 2 (4%)
 the handling of food, after, or both
 Daily before commencing work; daily after work; and during 1 (2%)
 the handling of food, immediately after, or both
 Clean surfaces under all circumstances 46 (92%)

Means of Cleaning/Washing
 Cold water and detergent 11 (22%)
 Hot water and detergent 39 (78%)
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Title Annotation:INTERNATIONAL PERSPECTIVES
Author:van Tonder, Izanne; Lues, Jan F.R.; Theron, Maria M.
Publication:Journal of Environmental Health
Article Type:Report
Geographic Code:6SOUT
Date:Nov 1, 2007
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