Keywords
Food Hygiene, Food Safety, Food handlers, Knowledge, Attitude, Practices, KAP
This article is included in the Manipal Academy of Higher Education gateway.
This article is included in the Agriculture, Food and Nutrition gateway.
Food Hygiene, Food Safety, Food handlers, Knowledge, Attitude, Practices, KAP
Food is an integral and indispensable part of all cultures. However, illness—or even death—may result if contaminated food is consumed. Measures that prevent contamination of food during processing, preparation, and food handling thereby ensuring that the food is safe to consume are termed as food safety. “Any disease of an infectious or toxic nature caused by, or thought to be cause by, the consumption of food or water” is how the World Health Organization (WHO) defines foodborne diseases (FBDs).1 FBDs continues to be the foremost public health challenge contributing to 420,000 mortalities and 600 million cases FBDs in 2010.2 This makes the impact of FBD comparable to diseases such as malaria, tuberculosis, and HIV/AIDS. Although the complete economic and social impacts of FBD are not fully known, they are estimated to be enormous and considerable.3 Instances of FBD have been reported from many countries around the world. LMICs have been hit particularly hard by instances of FBD4,5 as access to clean water is scarce and the foodservice sector in these countries is mostly unorganised and informal. The Federation of Indian Chambers of Commerce and Industry (FICCI) in its report of 20176 has indicated that about 66% of the foodservice establishments in India are in the unorganised sector. On the other hand, the possibility of wide-spread outbreak of FBD in high-income nations cannot be dismissed. In such countries, the highly consolidated structure of the foodservice industry with extensive and long supply chains has the potential to effect wide-spread occurrence of FBD as number of patrons frequenting such establishments is considerable.
The rise in eating out venues and accessibility to different cuisines are helping the food industry to post strong and sustained—except for a few periods of exception—growth for last two decades.7 The dining-out behaviour has seen continuous increase due to factors such as convenience, higher income, working women, nuclear families, and globalisation.8 The Indian domestic food service market is projected to be worth about INR 5 trillion with a CAGR of 10%.9
Evidence from many research studies10–15 suggest that food safety is an important consideration when selecting a dining-out destination. Czarniecka-Skubina, 2021 has reported an increased awareness amongst consumers about food safety and hygiene due to the ongoing COVID-19 pandemic.13 Overall impression of the establishment, inspection ratings, grooming and attire of staff members, and observed cleanliness are the elements identified by Henson et al. (2006) that influence customers’ perception of an establishment’s food safety.16 In their study, Sohn and Lee (2018) attribute the increase in number of restaurants and other foodservice operations that have an “open” kitchen design where patrons can observe the kitchen operations to patrons’ perception of offering better food quality and cleanliness.17 Consequently such establishments are becoming popular amongst patrons who value food safety and cleanliness.17,18
Many studies19–21 identify insufficient among food handlers on Knowledge, Attitude and Practices (KAP) as the reason behind instances of FBD. A study by Knight et al. (2007) found that a majority of consumers believed that the food safety aspect at restaurants is significantly lower than—amongst others—grocery stores or supermarkets.10 This perception of poor food safety at foodservice establishments in general and restaurants in particular has assumed significance as an instance of FBD at a foodservice business operation can have serious financial, societal, and economical implications. Grover and Dausch (2000) listed reduction in number of customers, adverse publicity, cost of litigation, and erosion of trust as the effects of a foodservice establishment being identified as the source of FB illness.22
The instances of FBD are highest—3 out of every 5 cases—for food served in foodservice settings like restaurants, cafés, bistros etc.23 Hedberg (2006) estimated that about 60% of these cases are due to unsafe food handling.24 However, these figures are significantly lower than the actual number of cases as only about 7% of the customers who became ill due to FBD informed the health authorities.16,25 The annual cost of illness in USA is about USD 6.9 billion for top five and between USD 51 to USD 77.7 billion for all foodborne pathogens.26,27 This economic burden coupled with the top five factors recognised by FDA28—poor personal hygiene, contaminated equipment, unsafe food sources, inadequate cooking, and incorrect holding temperature—for occurrence of FBD, indicate the significant contribution of foodservice establishments towards FBD and indicate the scope for limiting occurrences of FBD by engaging foodservice workers in the control of FBD by imparting relevant training.
Food hygiene practices such as keeping and cooking raw and cooked food separately at safe temperatures, using clean water for cooking are some of the ways to ensure food safety.29 Thus it is important for food handlers to have adequate knowledge and right attitude towards food safety and they should also ensure practicing proper food hygiene and safety while handling the food.30
Few systematic reviews of consumer’s Knowledge, Attitude and Practices (KAP) have been done previously.31–33 However, there is scant and insufficient synthesis of various studies on KAP of food handlers. Thus, there is a necessity of synthesizing evidence on KAP of food handlers with regard to food safety and hygiene. To cater to this need, a scoping review of peer and non-peer-reviewed articles and grey literature is planned.
The objective of this review is to find out the KAP of food handlers in food facilities as well as potential factors affecting it. The review will also attempt to identify the unaddressed gaps in the literature.
Updated methodological guidance by JBI was followed for preparing the scoping review protocol.34 Additionally, PRISMA Extension for Scoping Reviews35 and scoping review methodology by Arksey and O’Malley’36 was also referred.
The scoping review will be conducted in five different stages.
Inclusion criteria
The English language articles from the year 2011 year onwards will be considered for this review. Population, concept, context (PCC) mnemonic will guide the inclusion/exclusion criteria for this review.
Population
The review will include food handlers above 18 years of age. Food handlers working in restaurants and in other food establishments such as street food handlers, food processing units, school canteens, food courts will be considered for inclusion. The review will also consider studies where consumer’s perception of food handler’s KAP is provided. Food handlers in hospital settings will be excluded.
Concept
Food hygiene and safety is increasingly assuming importance in today’s dining out environment. Customers are increasingly and critically examining the hygiene and safety scores—whether formal or informal—to determine their eating-out venue. Recognising this, many foodservice businesses are now getting their business audited and displaying scores prominently to attract customers. While examining factors that influence choice of eating-out venue; consumers often consider, food safety and hygiene as one of the most prominent factor. Thus it is very important for the food handler’s to have apt KAP and they should develop positive food handling behaviours. Some definitions related to the concept of this review are mentioned below.
“Food safety is about handling, storing and preparing food to prevent infection and help to make sure that our food keeps enough nutrients for us to have a healthy diet”.37
“Food hygiene is defined as the measures and conditions necessary to control hazards and to ensure fitness for human consumption of a foodstuff taking into account its intended use”.38
“A KAP survey is a quantitative method (predefined questions formatted in standardized questionnaires) that provides access to quantitative and qualitative information. KAP surveys reveal misconceptions or misunderstandings that may represent obstacles to the activities that we would like to implement and potential barriers to behaviour change”.39
Studies involving different designs such as quantitative, qualitative and mixed method research designs will be considered for this review. We will also be including conference papers. However, letters to the editor, editorials, commentaries perspectives and reviews will be excluded.
Studies published in English, conducted between 2011 and 2022 (both years included), and relevant to the review will be identified by conducting the search on Medline (PubMed), Global Index Medicus, Web of Science, Scopus, ProQuest and Google Scholar. The keywords guiding the search will include “Food handlers”, “Knowledge”, “Practices”, “Attitude”, “KAP”, “Food Hygiene, “Food Safety”, “Restaurant”, “Food safety training”, “Food Hygiene training”, “Food service establishment”, “Behavior”, “Facilitators, “factors” “and “Barriers”. PCC mnemonic described in JBI methodology will guide the search. Also, the references of included articles included in the review will be hand searched to locate and include any relevant study that meet the inclusion criteria. The preliminary search conducted on PubMed (Table 1) combining keywords with Boolean operators will be refined and customized for other databases in consultation with the librarian.
All the citations from the databases search will be imported to Rayyan software. Records after removing duplicates will undergo title, abstract and full-text screening. A two stage identical screening process will be followed, where every article will be independently reviewed by two reviewers following pre-defined inclusion and exclusion criteria. A consensus approach will be used to resolve discrepancies among the reviewers. If the disagreement cannot be resolved this way, a third reviewer will be asked to adjudicate. Conclusively relevant sources will be retrieved in full. The selected full text will be reviewed in minute detail against the eligibility criteria independently. In case of further ambiguities about the eligibility of an article, it will be labelled and discussed with the third reviewer. Search results indicating the number of articles included and excluded at different screening stage and exclusion reasons at full text screening stage will be depicted in PRISMA flow chart.40
A piloted data extraction form will be used to collect the data relevant to research questions. Specific information on citation details, methodological characteristics and associated outcome measures of significance will be included in data extraction form. To ensure that the data is adequately extracted, the form will be pilot tested before final data extraction starts. Modifications will be incorporated as a result of piloting the extraction and will be documented in the scoping review. Two reviewer will independently extract the data from included studies. The discrepancies between reviewers will be discussed with a third reviewer. A request will be made to the authors of studies included in the review to obtain the required missing information. Preliminary data extraction/charting sheet is presented in Table 2.
Data extraction will be followed by a narrative summary supported by descriptive statistics. Synthesising data will involve study characteristics such as study type, participant characteristics, setting, results, outcome variables etc. Quantitative studies will be analysed using descriptive statistics, such as frequencies, percentage, measures of central tendency and standard deviation. Analysis will be conducted based on population (food handlers), study designs, theoretical approaches and methods, geographical location, year wise distribution of the studies, association measured with respect to KAP, factors associated with KAP and food service setting. Moreover, for qualitative studies, thematic analysis will be assimilated for the analysis.
This will be the first scoping review to provide aggregate summary of evidence on food handlers’ knowledge, attitude and practices in LMICs. It will map the coverage of the evidence available and existing gaps on the topic. The scoping study will employ a comprehensive search strategy which will be conducted on five electronic databases. Grey literature search on Google Scholar and citation search will also conducted to include all possible relevant articles. However, there are limitations to the search with respect to the language and number of databases covered. Non-English articles will be excluded due to lack of resources (human and monetary) to translate in English. Quality assessment of the included in scoping review will not be undertaken as it is not the mandatory requirement of the scoping review.
Figshare. PRISMA-P checklist. DOI: https://doi.org/10.6084/m9.figshare.20055176.v1
PD is the guarantor of this review protocol. PD, SK, KSN and VSD contributed to the title and concept genesis. PD drafted the protocol manuscript. All the authors have critically reviewed, proofread and given the final approval of the protocol version to be published.
The authors would like to thank Manipal Academy of Higher Education for providing the logistics and administrative support.
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Is the rationale for, and objectives of, the study clearly described?
Yes
Is the study design appropriate for the research question?
Yes
Are sufficient details of the methods provided to allow replication by others?
Yes
Are the datasets clearly presented in a useable and accessible format?
Not applicable
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Nutrition, Public health, systematic reviews.
Is the rationale for, and objectives of, the study clearly described?
Yes
Is the study design appropriate for the research question?
Yes
Are sufficient details of the methods provided to allow replication by others?
Yes
Are the datasets clearly presented in a useable and accessible format?
Yes
References
1. Haddaway NR, Collins AM, Coughlin D, Kirk S: The Role of Google Scholar in Evidence Reviews and Its Applicability to Grey Literature Searching.PLoS One. 2015; 10 (9): e0138237 PubMed Abstract | Publisher Full TextCompeting Interests: No competing interests were disclosed.
Reviewer Expertise: Food literacy and nutrition literacy, adolescent health, systematic reviews, narrative reviews, qualitative research, quantitative research, mixed methods
Alongside their report, reviewers assign a status to the article:
Invited Reviewers | ||
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Version 1 07 Jul 22 |
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