Effectiveness of Food Handler Training and Education Interventions: A Systematic Review and Meta-Analysis

Random forest models of food safety behavior during the COVID-19 pandemic

Machine learning approaches are increasingly being adopted as data analysis tools in scientific behavioral predictions. This paper utilizes a machine learning approach, Random Forest Model, to determine the top prediction variables of food safety behavioral changes during the pandemic. Data was collected among U.S. consumers on risk perception of COVID-19 and foodborne illness (FBI), food safety practice behaviors and demographics through online surveys at ten different time points from April 2020 through to May 2021; and post pandemic in May 2022. Random forest model was used to predict 14 food safety-related behaviors. The models for predicting Handwashing before cooking and Handwashing after eating had a good performance, with F-1 score of 0.93 and 0.88, respectively. Attitudes- related variables were determined to be important in predicting food safety behaviors. The importance ranking of the predicting variables were found to be changing over time.

Food Safety Knowledge, Attitudes, and Practices among Vegetable Handlers in Bangladesh

This study delves into the Knowledge, Attitudes, and Practices of vegetable handlers in Jashore Sadar, Bangladesh, specifically focusing on the crucial significance of food safety across the entire farm-to-fork process. Integrating quantitative and qualitative data provides a multifaceted depiction of this pivotal component within the food supply chain. Ten focus group discussions were conducted, and in total, 50 vegetable handlers were interviewed separately. In the survey, there were 17 questions on food safety knowledge, 16 on food safety attitudes, and 17 on food safety-related practices followed by vegetable handlers. We found that while approximately 60% of handlers had good knowledge about food safety, only about one-quarter of the interviewed vegetable handlers had good attitudes and practices toward food safety. The attitudes and practices of individuals involved in handling vegetables demonstrate a complex range of variations shaped by factors such as educational background, prior experience, and availability of food safety training. Concerns regarding the rising expenses linked to adherence to food safety regulations and a perceived lack of accountability among those involved were also noted. The interviewed wholesaler group reported that approximately BDT 100-150 (USD 0.91-1.371)/maund1 was incurred in maintaining proper safety practices, while the interviewed retailer group said costs would increase by BDT 20-40 (USD 0.18-0.36)/maund if they followed proper handling practices. It is important to note that vegetable handlers recognize the favorable economic consequences of implementing appropriate food safety measures. This study highlights the significance of implementing focused educational and policy interventions to address knowledge disparities and encourage the adoption of food safety procedures among individuals involved in handling vegetables.

Knowledge, attitude, and practice toward foodborne disease among Chinese college students: a cross-sectional survey

Background

More than 200 diseases are caused by eating food contaminated and the burden of foodborne disease is considered to be high worldwide. Foodborne diseases are an important public health issue, and the knowledge, attitudes and practices among college students are crucial in preventing outbreaks.

Objective

This study aimed to evaluate the current knowledge, attitudes, and practices (KAP) toward foodborne diseases among Chinese college students and to identify the factors influencing practice actions.

Methods

A cross-sectional study was conducted from April to November in 2023. A cluster random sampling method was used to enroll participants at Xihua University. The questionnaire including 47 items was used to collect the foodborne diseases information. An offline questionnaire was used to generate the surveys. Multiple linear regression was used to analyze the factors associated with foodborne disease knowledge, attitudes and practices.

Results

A total of 445 college students with a mean age of 19.76 ± 1.24 years were included in the study. The majority of participants were female (59.1%), of Han Chinese (95.1%), and nearly two-thirds were lower-year undergraduates (66.7%). Most participants (78.9%) were non-medical students, and 64.7% of participants were from rural areas. The KAP score of foodborne diseases was 79.21 ± 6.84. The knowledge, attitudes, and practices scores toward foodborne diseases were 8.76 ± 0.95, 10.50 ± 1.63, and 59.94 ± 6.48, respectively. In particular, there was a notable decrease in practice scores toward foodborne diseases among male students, ethnic minority students, and non-medical students. The significant predictors of practices were included gender (β = 0.11, p < 0.05), nationality (β = -0.12, p < 0.05), specialization type (β = -0.13, p < 0.05), residence (β = -0.11, p < 0.05).

Conclusion

These results revealed gaps in knowledge, attitudes, and practices regarding foodborne diseases, and the knowledge was at an insufficient level, the attitude was positive and practice was at a moderate and acceptable level. In general, the level of KAP was at a moderate and acceptable level. Gender, nationality, education level, specialization type, and residence were identified as crucial influencers on practices toward foodborne diseases. It is necessary to provide foodborne disease health education targeting this population in western areas, which can help improve students' knowledge, attitudes, and practices.

Training of food handlers on handwashing using a virtual reality environment is more effective than traditional training approaches in a randomized trial

Handwashing is an essential prevention step in foodservice, This randomized comparative study assessed the effectiveness of three training methods -virtual reality (VR), Glo-Germ (GT), and traditional face-to-face training (CT)- in improving handwashing practices among foodservice workers (n = 129). Training focused on the World Health Organization's 11-step handwashing process. Handwashing in the workplace was observed, in a pre- and post-test design, with microbiological swabs also taken. There was an increase in time spent on handwashing that was noticeable across all three groups (p < 0.05) with the highest in the VR group (50.16 ± 26.04 sec.). The mean number of handwashing steps increased across all groups, and the highest increase (8.91 ± 1.49 steps) was observed in the VR group. A statistically significant difference was observed among all groups regarding correctly performed steps, and the VR group showed the highest number of steps (p < 0.01). These findings suggest that VR-based training has value for enhancing hand hygiene practices in foodservice settings.

Food Safety Exam Phrasing for Food Service Employees

In many jurisdictions, foodservice workers are required to obtain food handler certification via written examination before being able to work. This study investigated the effect of the readability, or the ease in which one can read and comprehend written text, of food handler exam questions on exam performance. It was hypothesized that the reduction in cognitive load by improving the readability of exam questions would lead to improved scores. Participants received training in personal hygiene and basic food safety and were tested on their knowledge using questions that were worded using the traditional phrasing and updated phrasing that has improved readability. The results indicate that improved readability had a significant difference in the personal hygiene section but not on the basic food safety section. These results are due, in part, to the types of cognitive load (intrinsic vs. extraneous) that are required to solve different types of problems.

Effectiveness of Online Food-Safety Educational Programs: A Systematic Review, Random-Effects Meta-Analysis, and Thematic Synthesis

Online food-safety educational programs are increasingly important to educate different populations as technology and culture shift to using more technology. However, the broad effectiveness of these programs has yet to be examined. A systematic review, random-effects meta-analysis, and thematic synthesis are conducted to identify the effect size of online food-safety educational programs on knowledge, attitudes, and practices of consumers, food workers, and students and their respective barriers and recommendations. Online food-safety education was found to be of moderate and low effectiveness, with attitudes being the lowest in all populations. Consumers struggled with staying focused, and it was found that messaging should focus on risk communication. Students struggled with social isolation and a lack of time, and it was recommended that videos be used. Food workers struggled with a lack of time for training and difficulty understanding the material, and future programs are recommended to implement shorter but more frequent trainings with simple language. Future online food-safety educational programs should focus on incorporating social elements, as they can remain a huge barrier to learning. They should also focus on changing the participant's attitude to risk perception and beliefs in the importance of food safety.

Evaluation of the Handling Practices and Risk Perceptions of Dried Wood Ear Mushrooms in Asian Restaurants in the United States

In late 2020, dried wood ear mushrooms, a low-moisture food ingredient that had been imported and sold to restaurants, were linked to a foodborne outbreak of Salmonella Stanley, which sickened 55 individuals across the United States. These mushrooms are commonly used in Asian cuisine. It is unclear if the contaminated dried wood ear mushrooms that caused the foodborne illnesses were improperly handled during preparation. The objectives of this study are to assess the handling practices, risk perceptions, and food recall experiences of dried wood ear mushrooms in restaurant kitchens among Asian restaurant managers and chefs. We conducted a series of telephone interviews with managers and chefs of Asian restaurants in the United States who used dried wood ear mushrooms in making dishes. After reaching information saturation, a total of 25 restaurant managers and chefs participated in the interview. Our results showed that 76% of the participants did not keep track of package information, such as expiration date and lot number, and many participants reported using cold water for rehydration. Wood ear mushrooms were blanched before being used in all cold dishes and most stir-fry dishes, but less commonly in stew or ramen. Some participants (16%) did not view dried wood ear mushrooms as a raw food ingredient, and 16% did not perceive that low-moisture food ingredients constituted microbiological food safety risks. The majority of the participants had heard of food recalls, but only 17% knew about the dried wood ear mushroom recall, and even fewer had heard of food recalls of other low-moisture foods, like nuts and seeds (9%), and flour (4%). While this study shares similarities with previously published studies evaluating the handling practices of consumers and restaurant employees with respect to meat and poultry, it makes a distinctive contribution to the field of food safety as the first-of-its-kind to study the handling practices of a low-moisture food ingredient: dried wood ear mushrooms. This unique ethnic food ingredient has been associated with a past outbreak and multiple recalls in the United States. The findings of the study show the need to develop food safety educational programs that are tailored toward Asian restaurant food handlers and provide guidance to develop risk communication strategies for this niche audience.

Food safety culture in food companies: evaluation of the perception of food safety culture in three Tuscan food companies

The Commission Regulation (EU) No. 2021/382 (European Commission, 2021), amending the Regulation (EC) No. 852/2004 (European Commission, 2004), introduced the obligation for companies to establish and maintain a food safety culture (FSC). The methodology to evaluate, implement, and enhance the level of FSC is up to the individual companies. This study aimed to investigate the perception of FSC among the employees of 3 Tuscan medium-sized enterprises in the food sector, producing cured meat (A), dairy products (B), and frozen fish products (C). The survey was conducted through the development and administration of a questionnaire based on a 5 points Likert scale, referring to different aspects of FSC, organized in 6 sections with 5-6 statements each and subjected to a percentage of employees between 76 and 85%, classified also by the length of service (≤3 and >3 years). For all the companies, the minimum median and mode value for scores obtained by the different sections was 4, and the minimum median and mode value for the single statement was 3 (A, B; except for a bimodal value 2-4) and 4 (C). The section awareness and perception of risk showed the highest mean scores in all companies. As for the length of service, senior employees gave lower scores than junior ones in all sections in B and 3 sections in C. Overall, the results of the questionnaires showed a good perception of FSC, even though it was possible to identify some partial weaknesses.

Vendor Knowledge, Attitudes, and Practices Related to Food Safety in Low- and Middle-Income Countries: A Scoping Review

ABSTRACT

Foodborne diseases are a significant cause of illness in low- and middle-income countries (LMICs). Poor infrastructure, lack of regulatory oversight, and environmental conditions can increase food safety risks, particularly in traditional markets. Food vendors in traditional markets shoulder a heavy responsibility to keep food safe under often challenging conditions. The ability of these vendors to ensure food is safe is shaped by their knowledge, attitudes, and practices (KAP). Hence, understanding vendor KAP is important when designing interventions to improve food safety. To date most research on food vendors in LMICs has focused on vendors of ready-to-eat street foods and not on vendors of fresh food commodities. To fill this gap, a scoping review was undertaken to compile existing research on food safety KAP of vendors of food commodities in LMICs. PubMed, Google Scholar, Ovid Medline, and institutional Web sites of major research organizations were searched for original research articles and reports. Of 17,483 titles screened, 84 relevant studies were identified. Of the studies included, most were conducted after 2014 and focused on urban and periurban Africa. Most studies had a cross-sectional design with mixed methods (e.g., quantitative and qualitative analyses of vendor KAP through interviews and observations) and had small sample sizes (<50 participants). Common food value chains studied were dairy, meat, and fruits and vegetables. Very few studies included more than one type of commodity or value chain. Food vendor knowledge typically ranged from little to none, which was evident from observations of vendors operating under unsafe and unhygienic conditions, such as poor food handling and storage practices. Poor compliance with existing food safety policies, laws, and regulations was evident in some cases primarily due to either limited awareness of their existence or limited knowledge of how to implement them. However, vendors generally had positive attitudes toward food safety. No significant gaps were found between food safety knowledge and actual practices, although this correlation was not always examined rigorously in the reviewed studies. KAP and gaps between food safety behavior did not differ with vendor age or gender, type of product sold, or geography. Local government staff were identified as key enabling actors, interacting with food market vendors to foster improved food safety practices.

HIGHLIGHTS

A review of Canadian and international food safety systems: Issues and recommendations for the future

In January 2019, the Safe Food for Canadians Act/Safe Food for Canadians regulations (heretofore identified as SFCR) came into force across Canada and brought a more streamlined process to food safety practice in Canada. Food trade and production processes have evolved rapidly in recent decades, as Canada imports and exports food products; therefore it is critically important to remain aware of the latest advances responding to a range of challenges and opportunities in the food safety value chain. Looking through the optics of the recent SFCR framework, this paper places the spotlight on leading domestic and international research and practices to help strengthen food safety policies of the future. By shedding some light on new research, we also draw attention to international developments that are noteworthy, and place those in context as to how new Canadian food safety policy and regulation can be further advanced. The paper will benchmark Canada through a review study of food safety best practices by juxtaposing (i) stated aspirations with, (ii) actual performance in leading Organization for Economic Cooperation and Development (OECD) jurisdictions.

Hand Washing Observations in Fast-Food and Full-Service Restaurants: Results from the 2014 U.S. Food and Drug Administration Retail Food Risk Factors Study

ABSTRACT

Properly executed hand washing by food service employees can greatly minimize the risk of transmitting foodborne pathogens to food and food contact surfaces in restaurants. However, food service employee hand washing is often not done correctly or does not occur as often as it should. The purpose of this study was to assess the relative impact of (i) the convenience and accessibility of hand washing facilities; (ii) the maintenance of hand washing supplies, (iii) multiunit status, (iv) having a certified food protection manager, and (v) having a food safety management system for compliance with proper hand washing. Results revealed marked differences in hand washing behaviors between fast-food and full-service restaurants; 45% of 425 fast-food restaurants and 57% of 396 full-service restaurants were out of compliance for washing hands correctly, and 57% of fast-food restaurants and 78% of full-service restaurants were out of compliance for employee hands being washed when required. Logistic regression results indicated the benefits of accessibility and maintenance of the hand washing sink and of a food safety management system for increasing the likelihood of employees washing hands when they are supposed to and washing them correctly when they do.

HIGHLIGHTS

Program for Healthier School Cafeterias in Rio Grande do Sul, Brazil: Protocol for a Community-Based Randomized Trial

Background

School cafeterias can promote poor eating habits, as these retail outlets have a variety of foods considered to be nonnutritive and unhealthy. However, despite the need for effective preventive strategies, there is still disagreement on the best approach due to the lack of evidence on interventions to prevent and treat obesity in the school settings.

Objective

We aim to verify the efficacy of an educational intervention program to improve the hygienic conditions and the composition of the menu offered in school cafeterias in the state of Rio Grande do Sul, Brazil.

Methods

We will conduct a randomized, parallel, two-arm, community-based controlled study. Elementary and high schools, both public and private, in the State of Rio Grande do Sul, Brazil, that have a cafeteria will be eligible. Schools will be recruited and randomly assigned to the intervention (n=27) or control (n=27) group. The intervention group will receive an educational intervention program based on the guidelines issued by the Ministry of Health of Brazil, consisting of a 160-hour distance-learning qualification course, for 10 weeks, and using the Moodle platform and WhatsApp app. The intervention targets the owners and people in charge of the cafeterias, food handlers, principals, vice principals, teachers, pedagogical coordinators, dietitians, representatives of students' parents, and students over 16 years old. Meanwhile, the control group will receive only a printed copy of the book containing the guidelines used. The efficacy of the intervention will be determined by the hygienic conditions of the cafeteria and the composition of the menu offered, also considering the levels of processing of food sold. All outcomes will be analyzed as intention-to-treat and per-protocol. We will use covariance analysis or a generalized linear model for continuous data and ordinal logistic regression for ordinal categorical data. The level of statistical significance considered will be P<.05 for a 95% CI.

Results

This project was funded in early 2018. We administered the intervention program in 2019. All data have already been collected, and we are analyzing the data. The results are expected in 2021.

Conclusions

To our knowledge, this may be the first randomized controlled study in school cafeterias held in Brazil. The results will provide evidence for the formulation of public food and nutritional security policies and for the development of effective strategies to provide safe and healthy school meals.

Trial Registration

Brazilian Clinical Trials Registry RBR-9rrqhk; https://ensaiosclinicos.gov.br/rg/RBR-9rrqhk

International Registered Report Identifier (IRRID)

DERR1-10.2196/22680

Effect of Observational Evaluation of Food Safety Curricula on High School Students' Behavior Change

ABSTRACT

High school students have limited food safety knowledge and lack safe food handling skills. However, youth of high school age are frequently employed in food service and will prepare food for themselves. This study was conducted to evaluate the effectiveness of a food safety educational intervention for changing students' food handling behaviors, and the theory of planned behavior was used to construct factors that contribute to behavior change. A combination of stationary and wearable (GoPro) cameras was used to observe the food handling practices of high school students in key areas, including food thermometer use, hand washing and hand drying, glove changing, and environmental cleaning. The percentage of correct food handling techniques was measured categorically, and the number of groups who complied with thermometer use and environmental cleaning guidelines was recorded. The percentage of students using correct hand washing, hand drying, and glove changing techniques significantly increased in the postobservation cooking session. However, the percentage of correct hand washing and glove changing events remained <50% for certain subcategories: hand washing time (38%), hand washing after handling raw produce (36%) and touching skin (20%), changing gloves after gloves became contaminated or torn (47%), and washing hands between glove changes (15%). Students modified their behaviors to comply with subjective norms related to the study, including instructor expectations, but some students did not plan to change the behaviors they practiced at home. Students cited food handling behaviors they observed their parents using when making decisions about how to prepare food. This study highlights the need for the development of food safety educational interventions that encourage safe food handling skills and address influences from key subjective norm groups.

HIGHLIGHTS

Restaurant Policies and Practices Related to Norovirus Outbreak Size and Duration

ABSTRACT

Norovirus is the leading cause of foodborne illness outbreaks in the United States, and restaurants are the most common setting of foodborne norovirus outbreaks. Therefore, prevention and control of restaurant-related foodborne norovirus outbreaks is critical to lowering the burden of foodborne illness in the United States. Data for 124 norovirus outbreaks and outbreak restaurants were obtained from Centers for Disease Control and Prevention surveillance systems and analyzed to identify relationships between restaurant characteristics and outbreak size and duration. Findings showed that restaurant characteristics, policies, and practices were linked with both outbreak size and outbreak duration. Compared with their counterparts, restaurants that had smaller outbreaks had the following characteristics: managers received food safety certification, managers and workers received food safety training, food workers wore gloves, and restaurants had cleaning policies. In addition, restaurants that provided food safety training to managers, served food items requiring less complex food preparation, and had fewer managers had shorter outbreaks compared with their counterparts. These findings suggest that restaurant characteristics play a role in norovirus outbreak prevention and intervention; therefore, implementing food safety training, policies, and practices likely reduces norovirus transmission, leading to smaller or shorter outbreaks.

HIGHLIGHTS

A Systematic Review and Meta-Analysis of the Effects of Food Safety and Hygiene Training on Food Handlers

Foodborne diseases are a significant cause of morbidity and mortality worldwide. Studies have shown that the knowledge, attitude, and practices of food handlers are important factors in preventing foodborne illness. The purpose of this research is to assess the effects of training interventions on knowledge, attitude, and practice on food safety and hygiene among food handlers at different stages of the food supply chain. To this end, we conducted a systematic review and meta-analysis with close adherence to the PRISMA guidelines. We searched for training interventions among food handlers in five databases. Randomized control trials (RCT), quasi-RCTs, controlled before-after, and nonrandomized designs, including pre-post studies, were analyzed to allow a more comprehensive assessment. The meta-analysis was conducted using the random-effects model to calculate the effect sizes (Hedges's g) and 95% confidence interval (CI). Out of 1094 studies, 31 were included. Results showed an effect size of 1.24 (CI = 0.89-1.58) for knowledge, an attitude effect size of 0.28 (CI = 0.07-0.48), and an overall practice effect size of 0.65 (CI = 0.24-1.06). In addition, subgroups of self-reported practices and observed practices presented effect sizes of 0.80 (CI = 0.13-1.48) and 0.45 (CI = 0.15-0.76) respectively.

A systematic review and meta-regression of single group, pre-post studies evaluating food safety education and training interventions for food handlers

BACKGROUND

Food handlers working in retail and food service establishments are a frequent source of foodborne disease outbreaks. Numerous studies have investigated different education and training approaches to improve their safe food handling knowledge, attitudes, and practices. Frequently, these studies use a single group, pre-post design, measuring changes before and after an intervention without a separate control group.

OBJECTIVES

We conducted a systematic review of these studies to identify their key characteristics and to evaluate possible predictors of between study heterogeneity in their estimates of intervention effect.

METHODS

the review steps included a comprehensive search; relevance screening; article characterization; risk-of-bias assessment; data extraction; and meta-regression on five outcome categories: attitudes and beliefs, knowledge, behaviours, food premise inspection scores, and aerobic plate counts.

RESULTS

Among 85 relevant studies identified, the most commonly investigated intervention type was in-person, group-based training courses (81%). Interventions primarily targeted food handlers in educational institutions and restaurants (32% and 31%, respectively). The most frequently measured outcome was food handler knowledge (66%). Studies mostly (89%) covered multiple food safety content areas, primarily targeting personal hygiene (88%) and avoiding cross-contamination (87%). All studies were rated as 'critical' risk of bias given the lack of an independent control group. Significant intervention effects were found for all outcome categories, but substantial heterogeneity was also identified. Studies that informed their intervention from formative research reported larger effect sizes for attitude and belief outcomes, those that based their intervention on a theory of behaviour change reported larger effect sizes for behaviour outcomes, and those published in grey literature sources reported larger effect sizes for behaviour and knowledge outcomes.

IMPLICATIONS

The results of this review have identified food safety training and education research gaps and future opportunities.