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Accepted Manuscript

A systematic review and thematic synthesis of qualitative research studies on factors


affecting safe food handling at retail and food service

Abhinand Thaivalappil, Lisa Waddell, Judy Greig, Richard Meldrum, Ian Young

PII: S0956-7135(18)30040-9
DOI: 10.1016/j.foodcont.2018.01.028
Reference: JFCO 5959

To appear in: Food Control

Received Date: 14 November 2017


Revised Date: 28 January 2018
Accepted Date: 29 January 2018

Please cite this article as: Thaivalappil A., Waddell L., Greig J., Meldrum R. & Young I., A systematic
review and thematic synthesis of qualitative research studies on factors affecting safe food handling at
retail and food service, Food Control (2018), doi: 10.1016/j.foodcont.2018.01.028.

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1 A systematic review and thematic synthesis of qualitative research studies on factors affecting

2 safe food handling at retail and food service

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5 Abhinand Thaivalappil*1, Lisa Waddell2, Judy Greig2, Richard Meldrum1, and Ian Young1

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7 School of Occupational and Public Health, Ryerson University, 350 Victoria Street, POD 249,

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8 Toronto, Ontario, Canada, M5B 2K3
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9 National Microbiology Laboratory, Public Health Agency of Canada, 160 Research Lane, Suite

10 206, Guelph, Ontario, Canada, N1G 5B2


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20 * Author for correspondence: Telephone: +1 519-590-1316, Email: athaival@uoguelph.ca

21 Emails: athaival@uoguelph.ca (A. Thaivalappil), lisa.waddell@canada.ca (L. Waddell),

22 judy.greig@canada.ca (J. Greig), meldrum@ryerson.ca (R. Meldrum), and iyoung@ryerson.ca

23 (I. Young)
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24 Abstract

25 Foodborne disease outbreaks are frequently associated with improper food handling at

26 retail and food service settings, indicating a need to improve food safety practices among food

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27 handlers. Many qualitative research studies have been conducted to examine food handlers'

28 opinions, perspectives, and experiences with safe food handling in an effort to understand the

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29 factors associated with their use of such practices. The aim of this systematic review was a

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30 synthesis of the findings from relevant studies to identify the main across-study themes and

31 develop recommendations for interventions and future research. The following steps used to

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32 conduct the review were developed a priori as part of the study protocol: a comprehensive
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33 search strategy; relevance screening of abstracts; relevance confirmation of articles; study quality

34 assessment; data extraction; thematic synthesis of results; and quality-of-evidence assessment.


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35 We identified 28 relevant articles reporting on 26 unique studies. Behavioural determinants were

36 grouped according to constructs from the Theoretical Domain Framework, and further mapped
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37 onto the COM-B model of the Behaviour Change Wheel. A total of 13 categories of
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38 determinants of safe food handling were identified. Of these categories, overall confidence

39 ratings were assigned and rated as high (n=9) and moderate (n=4). The analysis revealed that: 1)
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40 food handlers typically demonstrated good knowledge and had positive attitudes toward training;
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41 2) environmental factors (e.g. policies, resources), reinforcement (e.g. posters, reminders),


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42 emotions (e.g. stress), and social influences played a significant role in food handlers' intentions

43 and practices; 3) food handlers were confident in their abilities and showed positive beliefs

44 relating to consequences of unsafe food handling; 4) they demonstrated a lack of motivation to

45 perform safe food handling practices and experienced lapses in concentration; and 5) culturally

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46 diverse food handlers had unique barriers such as language and communication. Areas for future

47 research and recommendations for policy and practice are discussed.

48 Keywords: systematic review; food safety; behavior; food handling; qualitative research;

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49 restaurants;

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51 1. Introduction

52 Foodborne illness has a significant health and economic burden worldwide, and these

53 illnesses are frequently associated with poor food handling practices in retail and food service

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54 locations. For example, 902 foodborne disease outbreaks were reported in the United States (US)

55 in 2015, resulting in 15,202 illnesses, 950 hospitalizations, and 15 deaths (Centers for Disease

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56 Control and Prevention (CDC), 2015). Similarly in Canada, 115 foodborne disease outbreaks

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57 were reported from 2008-2014, of which nearly one-third were attributed to exposures in food

58 service establishments. In the US, an estimated 55-60% of all outbreaks were from restaurants

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59 while 14% were associated with foods prepared at catering and banquet facilities, although it is
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60 important to consider restaurant-associated outbreaks tend to be reported more frequently than

61 other types (Angelo, Nisler, Hall, Brown, & Gould, 2017; Bélanger, Tanguay, Hamel, &
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62 Phypers, 2015; Centers for Disease Control and Prevention (CDC), 2015). The contributing

63 factors leading to a high proportion of foodborne disease in these settings are related to food
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64 handlers’ health, hygiene, and use of recommended safe food handling practices (Angelo et al.,
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65 2017). This suggests that there is a need to improve food handlers’ behaviours more effectively

66 to prevent foodborne illness associated with these settings.


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67 Qualitative research studies provide insights into the possible factors which influence
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68 workers’ food safety practices, and this can assist in guiding the development of appropriate
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69 behaviour change interventions. A number of qualitative research approaches (e.g. open-ended

70 interviews, focus groups) have been used to study the complex factors affecting food safety

71 behaviours in retail and food service settings (Arendt et al., 2012; Clayton, Clegg Smith, Neff,

72 Pollack, & Ensminger, 2015; Machado, Monego, & Campos, 2014; Ovca, Jevšnik, & Raspor,

73 2017). Qualitative research allows researchers to gather in-depth data from participants about

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74 why they engage (or do not engage) in food safety practices, and it can be used to discover

75 employees' motivators, barriers, and perceptions toward food safety (Arendt et al., 2012).

76 Theories of behaviour change provide frameworks that organize and explain the

77 interrelationships between various determinants of an individual’s behaviour (Davis, Campbell,

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78 Hildon, Hobbs, & Michie, 2015; Prestwich, Webb, & Conner, 2015). A recent review identified

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79 >80 different behaviour change theories that can be used in the context of health-related

80 behaviours (Davis et al., 2015). The Theoretical Domains Framework (TDF) was developed as

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81 an integrated behaviour change theory, including constructs from >30 different theories, to help

82 explain factors that affect the use of health-related behaviours (Cane, O’Connor, & Michie,

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2012). It consists of 14 domains of theoretical constructs categorizing the possible influences on
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84 behaviour (Cane et al., 2012). The framework can be used with the Behaviour Change Wheel

(BCW), which is a comprehensive theory-based approach to designing interventions for health-


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86 related behaviour change (Cane et al., 2012; Michie et al., 2011). The BCW characterizes
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87 behaviour into three larger domains: Capability (an individual's psychological and physical
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88 capacity to engage in the activity involved); Opportunity (factors external to the individual that

89 make the behaviour possible or prompt it); and Motivation (processes in the brain that energize
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90 and direct behaviour in an individual) (Cane et al., 2012; Michie et al., 2011). These three

91 elements, also known as the COM-B model, interact with each other and jointly influence an
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92 individual’s behaviour (Michie et al., 2011). The TDF, linked with the COM-B model of the
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93 BCW, can help to identify which factors have the greatest impact on an individual’s behaviour

94 (e.g. safe food handling), and therefore can aid intervention designers, policymakers, and

95 practitioners in this field to select which segments to target to facilitate behaviour change (Cane

96 et al., 2012).

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97 The purpose of this study was to conduct a systematic review and thematic synthesis of

98 qualitative primary research studies investigating the determinants of safe food handling

99 behaviours among food handlers working at the retail and food service levels. The review

100 objective was to produce new interpretations of the primary qualitative research using the

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101 domains of the TDF, and linking those to the COM-B model, to provide guidance for future

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102 intervention development in this area. No previous study has implemented structured and

103 transparent knowledge synthesis methods to identify, evaluate, and synthesize across-study

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104 themes using this technique for qualitative research in this area. The results can be used by

105 decision-makers to inform and guide which factors should be targeted for future interventions to

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more effectively influence behaviour change among food handlers.
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108 2. Material and Methods

109 2.1 Review approach


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110 This review was conducted following the guidelines in the Cochrane Collaboration

111 handbook (Higgins & Green, 2011) and Thomas and Harden's (2008) guidelines for thematic
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112 synthesis. The review was reported in accordance with the “Enhancing transparency in reporting

113 the synthesis of qualitative research” (ENTREQ) framework, which is a reporting guideline for
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114 qualitative research syntheses (Tong, Flemming, McInnes, Oliver, & Craig, 2012). A copy of the
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115 review protocol and forms are available as supplementary information. The review question was:

116 "What are the determinants of safe food handling behaviours among food handlers at retail and

117 food service?" The review was part of a larger study that investigated quantitative and qualitative

118 research in this area; however, this article reports only on the qualitative studies identified in the

119 review. The population of interest was food handlers (e.g. employees, managers, caterers, chefs)

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120 who prepare and/or serve food at retail and food service premises (e.g. restaurants, delis, butcher

121 shops, grocery stores, hospitals, schools, and other institutions). Exclusions were made on

122 research involving food safety education and training interventions (unless qualitative data was

123 gathered before intervention delivery); food handlers at the pre-harvest and processing levels;

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124 and studies that investigated street food vendors. The outcome of interest was safe food handling

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125 (personal hygiene, cross-contamination prevention, adequate cooking of food, and time-

126 temperature control) in relation to microbial food safety. Behaviours related to other hazards

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127 such as allergens were excluded from this review. Any qualitative or mixed-method primary

128 research study published in English, French, or Spanish was considered for inclusion.

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129

130 2.2 Search strategy


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131 A comprehensive search strategy was developed, conducted on January 20, 2017, and
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132 updated on June 15, 2017. It was implemented in the following bibliographic databases: Scopus,
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133 PubMed, CAB Abstracts, Food Safety and Technology Abstracts, PsycINFO, CINAHL, Health

134 and Safety Science Abstracts, Risk Abstracts, and ProQuest Dissertations and Theses. The search
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135 algorithm contained food safety terms (e.g. food safety, food hygiene), population terms (e.g.

136 handler, restaurant, worker), behavioural determinant terms (e.g. attitude, knowledge), and
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137 outcome terms (e.g. behaviour, practice, qualitative). The algorithm was pre-tested using Scopus
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138 to ensure the efficient capture of articles.

139 Grey literature, such as government research reports, were captured through a series of

140 Google searches using simple search strings (e.g. "food handler food safety focus groups"). Only

141 the first 100 hits of each search were examined for practicality reasons (Canadian Agency for

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142 Drugs and Technologies in Health, 2015). The reference lists of all relevant articles were also

143 examined to gather any relevant articles the searches may have missed.

144

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145 2.3 Relevance screening, data extraction, and quality assessment

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146 Following identification, the titles and abstracts of articles were assessed for relevance

147 using a structured screening form. Full articles of relevant references were obtained, confirmed

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148 for relevance, and key characteristics were extracted using another structured form. This form

149 captured study characteristics such as: publication type and year; study methodology (e.g. data

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collection methods and tools); and details on the target population and setting (e.g. food premise
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151 type, workers’ role, socio-demographics) investigated. The relevant articles were then critically
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152 appraised using a quality assessment form adapted from previously developed critical appraisal

153 tools for qualitative research (Critical Appraisal Skills Programme, 2013; Walsh et al., 2006;
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154 Young & Waddell, 2016). The form contained eight individual quality criteria including: the
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155 scope and purpose of the study; study design; sampling strategy; analytic approach; clearly stated

156 findings and interpretations; researcher reflexivity; ethical considerations; and study relevance
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157 and transferability (Walsh et al., 2006). The appraisal tool was used to identify the integrity,

158 transparency, and limitations of qualitative research studies in this review (Walsh et al., 2006).
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160 2.4 Review management

161 All identified citations from the searches were de-duplicated so each citation only occurred

162 once in the reference management program RefWorks (ThomsonResearchSoft, Philadelphia,

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163 PA) database. References were then imported into the systematic review software program

164 DistillerSR (Evidence Partners, Ottawa, Canada) for review management and progress. Pre-

165 testing of forms (50 abstracts for relevance screening; five articles for data extraction; and five

166 articles for quality assessment) were completed by four independent reviewers to ensure

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167 consistency and identify the need to clarify any questions. For relevance screening, the reviewing

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168 proceeded when kappa agreement scores between reviewers were ≥0.8. Once the forms were

169 pre-tested, the remaining articles were reviewed by two independent reviewers each. Any

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170 discrepancies were discussed until consensus was reached. All data were exported as Excel

171 spreadsheets for analysis.

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172

173 2.5 Analysis


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174 The qualitative analysis was conducted using a modified thematic synthesis approach as
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175 presented by Thomas & Harden (2008). This approach was selected because it went beyond the
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176 content of the primary studies by allowing the authors to present new interpretations in a

177 transparent way (Thomas & Harden, 2008). We reviewed each relevant article's results sections
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178 and independently completed line-by-line coding of food handlers' interpretations of their

179 experience and the authors' interpretation of food handlers' experience, termed "first-order" and
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180 "second-order" interpretations, respectively. The resulting themes were called "third-order"
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181 interpretations.

182 We used a deductive approach to coding, by using the 14 theoretical domains of the TDF

183 as key codes in the codebook (Cane et al., 2012). The codebook is available as supplementary

184 material. Additional inductive codes were also added to the codebook during reviewing. The

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185 reviewers met to discuss and review their findings periodically during the coding process. Once

186 both reviewers completed coding on all articles, the findings were merged, discussed and

187 mapped to the BCW's COM-B model, similar to Cane et al. (2012) but with slight modifications.

188 All coding was conducted using the PDFs of each article in the NVivo 10 qualitative analysis

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189 software (QSR International, Doncaster, Australia).

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190 To assess confidence in the review findings, we adapted and used the Confidence in the

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191 Evidence from Reviews of Qualitative research (CERQual) approach (Lewin et al., 2015). Using

192 this in a qualitative evidence synthesis allowed the authors to determine how much confidence to

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193 place in the findings. The CERQual approach is similar to the Grading of Recommendations
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194 Assessment, Development, and Evaluation (GRADE) approach commonly used in systematic

195 reviews of interventions, but designed specifically for use in qualitative evidence synthesis
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196 (Lewin et al., 2015). We applied this approach for every theme in this review (themes consisted

197 of TDF domains and any additional constructs identified through inductive coding).
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198 This review followed the same modified CERQual approach that was used in a previous

199 qualitative synthesis (Young & Waddell, 2016). The CERQual assessment was based on four
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200 components: 1) methodological limitations (the degree of data richness and quantity of data); 2)

201 relevance (the extent to which the body of evidence from the studies is applicable to the review
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202 question); 3) coherence (the consistency of findings across studies); and 4) adequacy of data
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203 (extent of quality assessment deficiencies) (Lewin et al., 2015). Each component was rated as

204 having no concerns, minor concerns, moderate concerns, or substantial concerns.

205 After applying the individual CERQual ratings, an overall confidence rating was then

206 determined. Overall confidence was rated as: high (it is highly likely that the review finding is a

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207 reasonably representation of the phenomenon of interest); moderate (it is likely that the review

208 finding is a reasonable representation of the phenomenon of interest); or low (it is unclear

209 whether the review findings are a reasonable representation of the phenomenon of interest). A.T.

210 conducted a preliminary CERQual assessment; I.Y. reviewed the assessment and validated it.

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211 Both authors were involved in the discussion and finalization of individual and overall ratings.

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212

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213 3. Results

214 3.1 Study characteristics

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215 A flow chart of the qualitative review process is shown in Figure 1. In total, 28 relevant

216 articles were identified that represented 26 unique studies. A summary of the descriptive
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217 characteristics of the articles and studies is shown in Table 1. Most studies were strictly

218 qualitative (vs. mixed-method) (65%), used interviews to collect qualitative data from
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219 participants (62%), did not specify the qualitative methodology used (85%), and did not report
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220 being guided by one or more established theories of behaviour change (81%). The types of food

handlers investigated included managers, chefs, employees, and hospitality management students
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222 (Table 1). The most commonly investigated type of food premise was restaurants (54%). The
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223 median publication year of relevant articles was 2010 (range 2001-2016). The median sample
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224 size of the relevant studies was 31 (range 4-205). Among studies that conducted one-to-one

225 interviews (n=16), the median number of interviews per study was 25 (range 4-205). Among

226 studies that conducted focus groups (n=9), the median number of groups conducted per study

227 was 4 (range 1-15).

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228 A summary of the study quality assessment results is shown in Table 1. Criteria which were

229 most commonly deficient included: not clearly describing the method of analysis (68%), not

230 providing evidence of researcher reflexivity (46%), and not sufficiently describing or reporting

231 ethical considerations (39%). Detailed study characteristics, quality assessment ratings, and a

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232 citation list of all relevant studies are presented as supplementary information.

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233 Figure 1

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234 Table 1

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236 3.2 Thematic analysis

237 We identified 12 relevant constructs from the TDF and one additional inductive theme.
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238 These are shown in Table 2 organized under seven behavioural determinant categories from the
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239 BCW’s COM-B model. Each of these themes are described in detail below and supported with
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240 illustrative quotes from food handlers as reported in those studies. A summary of the CERQual

241 confidence ratings for each theme is shown in Table 2. Detailed CERQual assessments and
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242 criteria ratings for each theme are available as supplementary information.

243 Table 2
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245 3.2.1 Capability – physical

246 High confidence was determined for this theme, which encompassed the importance of

247 training to improve food handlers’ skills to engage in food safety behaviours. Overall, training

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248 was viewed favourably by food handlers across studies in this review. However, some believed

249 the training they received was common sense or irrelevant to their day-to-day duties. Participants

250 occasionally received conflicting information from different sources (e.g. supervisor instruction,

251 training material) which was sometimes noted to lead to confusion:

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252 “I pretty much learned three different ways to do stuff, and like there were some

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253 congruencies but then...for a lot of other stuff, it just wasn't.” (Abidin, Arendt, &

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254 Strohbehn, 2014)

255 Furthermore, food handlers viewed training as the degree to which management valued its

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256 employees. When training was not offered, participants stated that they did not feel valued by
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257 management. Both managers and employees specified a need for more efficient training

258 methods:
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259 “Turnover is a big issue for us, […] we have high turnover just with student employees.
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260 And so I think it needs to happen, […], efficient training needs to happen earlier.”
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261 (Roberts, Arendt, Strohbehn, Ellis, & Paez, 2012)

Participants also provided comments to improve training sessions such as expressing a


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263 desire to give input and have a two-way communication with the trainer; citing a need to
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264 customize training as different groups have different needs and prefer to learn in different ways;
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265 and being taught why tasks are followed a certain way instead of simply what is right and wrong:

266 “So I watched a video on how to make sandwiches and then it’s like ‘ok go and make

267 sandwiches’ and so I am taught now to physically make sandwiches but I am not taught on

268 cross contamination or any sort of temperature stuff or anything like that.” (Arendt et al.,

269 2014)

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270

271 3.2.2 Capability – psychological

272 We identified two TDF constructs under this theme: knowledge; and memory, attention,

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273 and decision making processes. Under knowledge, participants showed good understanding of

274 most safe food handling practices, with some exceptions where they fell short, such as stating

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275 correct cooking temperatures of food. In addition, managers claimed employees did not know

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276 that glove use could still lead to cross contamination. This observation was consistent in other

277 studies where participants indicated they did not know about correct hygiene practices or

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278 temperature control.
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279 “I thought that because I was wearing gloves I did not need to wash my hands because I am
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280 already covering them.” (Arendt, Strohbehn, & Jun, 2015)

281 Some participants were unfamiliar with hazard analysis and critical control point (HACCP)
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282 systems, whereas most managers acknowledged that they did not know the full scope or benefits
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283 of HACCP. Some staff also seemed to be unaware of the risks of foodborne illness in the food

they were preparing, and some reported using their senses (e.g. smell, taste, sight) to determine
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285 whether food had gone bad or was done cooking.


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286 “No, I think more the risk is in some cases like with E. coli, Staphylococcus, but it doesn’t
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287 affect restaurants. I don’t think restaurants are particularly bad. Its retail I think, [retail],

288 yes, the big cases you hear about.” (Taylor, 2008a)

289 Memory, attention, and decision making processes also affected food-handlers’ behaviours.

290 Participants in many studies reported that they often forgot to perform the necessary food safety

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291 practices, despite acknowledging the importance of following the practices. The reasons given

292 for this included being busy, having to perform multiple tasks at the same time, managers not

293 being around to remind them, lack of support following training, and fatigue.

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294 “My head is always overburdened by all the orders we receive.” (Machado et al., 2014)

295 “I know I should do it…I just forgot.” (Gilling, Taylor, Kane, & Taylor, 2001)

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296

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297 3.2.3 Motivation – automatic

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This theme represented three TDF constructs: behavioural regulation; emotion; and
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299 reinforcement. Regarding the former, we found high confidence in the importance of habits,

300 which participants reported were hard to break once they were formed. It was noted that food
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301 handlers often bring bad habits from home; thus, participants indicated that new food handlers
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302 should aim to build correct habits when they first enter the industry. Participants stated that once
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303 a good habit was formed, it became second nature.

304 “[It’s about] making sure no one gets food poisoning – we just go through a routine, once
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305 you get it, everything follows.” (Brough, Davies, & Johnstone, 2016)
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306 We found high confidence in the construct of reinforcement. Having detailed food safety
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307 procedures, reward-based systems, guidelines, posters, signs, and consequences (e.g. fines,

308 health violations) were helpful in promoting food safety practices. Participants generally wanted

309 to be appreciated and rewarded for their good behaviours – some even mentioned they wanted

310 immediate gratification, which did not need to be monetary. Manager presence and

311 communication was also identified as a facilitator for safe food handling. Participants indicated

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312 that they were influenced by public health inspections, which motivated them to improve food

313 safety practices. However, some participants felt that inspectors can be too strict and

314 inconsistent.

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315 “The chance to do something different and actually get a formal qualification...they were

316 quite interested in it, I was myself as well, it's nice to get something down on paper and get

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317 a certificate for it...it just shows that they're good at what they do.” (Mortlock, 2002)

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318 “The public health officers visit us often; they give us the reports which we use to improve

319 our kitchen.” (Nyamari Jackim, 2013)

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The final domain under this theme was emotion – we identified moderate confidence for this
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321 finding. Most of the emotions expressed by participants related to fear, worry, and pride. Fear
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322 and worry stemmed from not wanting to make customers sick, lose their job, and negatively

323 affect their reputation and business.


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324 "I was always worrying, I still worry a bit about eggs, you know, if the dates on them’s off,
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325 I will throw them away." (Taylor, 2008b)


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326 Some food handlers took pride and enjoyment in their work, which they said facilitated safe

327 food handling behaviours. Some emotions were seen as barriers to food safety, such as stress,
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328 pressure, frustration, and apathy from staff and management.


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329 “If you’re slow, you’re not going to last, you’ll get pushed out, they’ll cut your hours and

330 all that stuff.” (Clayton, Clegg Smith, Neff, Pollack, & Ensminger, 2015)

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332 3.2.4 Motivation – reflective

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333 We rated high confidence for all TDF constructs under this theme: beliefs about capabilities;

334 beliefs about consequences; intentions; and professional role and identity.

335 Most participants felt confident in their ability to implement food safety practices and serve safe

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336 food to customers, with the exception of glove use. Participants found gloves to be a nuisance,

337 stating that they interfered with tasks, had to be changed too frequently, and were uncomfortable.

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338 Regarding HACCP implementation, some managers believed it was not suitable for their

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339 business, while others felt that everyone could benefit from HACCP programs. When first being

340 introduced to HACCP, many managers were apprehensive, and found the material complex and

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341 difficult to understand.
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342 “I can’t stand gloves. I try. I’ll mix stuff with gloves on, but then I end up taking them off.

343 They get tacky and sticky, and, at least for safety, gloves on a hot line are not needed. So
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344 we just constantly wash our hands. Besides, they [gloves] melt.” (Torres, 2013)
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345 “I can’t do HACCP, I don’t know enough about food microbiology and advanced stuff like
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346 that.” (Gilling et al., 2001)

Regarding beliefs about consequences, most food handlers followed safe practices because
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348 they did not want their customers to contract foodborne illnesses, and to avoid being
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349 reprimanded by their superiors. However, some managers stated that implementing HACCP or
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350 other food safety standards would not make any positive impact on food safety.

351 “[A]s far as sanitizing we just go a little further than maybe what we have to because we

352 are not gonna let somebody come in and say you didn’t do something right and all these

353 kids are sick.” (Arendt et al., 2014)

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354 “When you have a facility with good practices you don’t have to cook those things to those

355 temperatures.” (Torres, 2013)

356 Regarding intentions, participants were generally interested in learning more about food

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357 safety. However, most participants outlined a lack of motivation and laziness towards

358 implementing recommended food safety behaviours. Some mentioned behavioural inertia (i.e.

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359 being set in their ways and not wanting change), not being paid enough, a lack of belief about the

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360 effectiveness of practices, and a lack of consequences as reasons for their lack of motivation.

361 Other managers felt their current food safety setup was just as effective as HACCP and felt

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362 HACCP was an additional burden. Some participants admitted that they were only motivated
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363 about food safety issues when they knew an inspector was going to make a visit, and reverted to

364 their existing habits following an inspection.


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365 “Sure, everyone takes those shortcuts, I’m sure it happens every single day if the laziness
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366 kicks in, that’s where they’re saving time or skipping steps.” (Torres, 2013)
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367 Many participants indicated that their professional role and identity influenced their food

368 safety behaviours. Food handlers believed that they were responsible for their customers’ health
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369 and wanted to maintain a good relationship with their customers. However, participants often

370 indicated that customers were more concerned about prices than food safety. Managers were
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371 aware that they were seen as role models for food safety and that their actions would influence
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372 staff in the workplace.

373 “If you have people that like their job and they enjoy what they are doing, they will make

374 sure that everything is good. They want to make good food because they want the

375 customers to come back because they want to be at that job.” (Clayton et al., 2015)

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376

377 3.2.5 Opportunity – physical

378 This theme consisted of the TDF construct “environmental context and resources”, and was

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379 rated as high confidence. Workplace policies and management commitment and culture were

380 identified as key determinants of food safety practices among food handlers. For example, many

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381 participants indicated that a lack of paid sick days and worker insurance led to them working

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382 while ill. In addition, participants indicated that poor practices by managers and a lack of

383 consistency in enforcing food safety policies negatively affected their behaviours.

384
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“I kinda feel like the upper management doesn’t always like enforce everything and so, me
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385 going in and saying, “Don’t drink that pop when you’re cooking food,” that’s like nothing
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386 because the upper management walks by and gives ‘em pop or whatever, you know. To

387 me, I kinda like feel like I’m, it’s not really effective because it’s not consistent across the
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388 board.” (Roberts et al., 2012)


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389 Participants indicated that food safety behaviours such as handwashing were often not

implemented during busy periods. The high turnover of employees in many establishments was
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390

391 noted to create additional pressures and food safety lapses due to being understaffed.
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392 Understaffed situations also created a crossover of responsibilities (e.g. cleaning bathrooms and
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393 then going back to cooking food). A lack of space and personnel, poor accessibility of resources

394 (e.g. handwashing stations), a lack of resources (e.g. soap, clean uniforms), and paperwork

395 burdens were also cited as reasons for not following various recommended food safety practices.

396 “A lot of kitchens I have worked in, they will have access to only a couple of sinks, some

397 of them don’t work properly, some of them a lot of times will sit stuff in the sink, or block

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398 it with things in the kitchen, like tubs of bread or whatever. They will make the sink

399 completely inaccessible to you.” (Clayton et al., 2015)

400 Financial constraints were also important for many food handlers and managers, particularly

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401 for small, independent businesses. For example, participants noted that they often did not have

402 enough funds to send staff to external food safety training courses. Some participants stated that

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403 they followed unsafe practices to save money (e.g. changing gloves less frequently, using

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404 expired products, and not washing clothing regularly).

405 “In a large company there’s more chance to take people out, send them on HACCP training

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406 courses. We haven’t got the funds to do that, and we can’t spare the people.” (Gilling et al.,
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407 2001)
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408 “I don't have 8 extra hours to pay them to be [off] the floor. It needs to be short, a 10-

409 minute training.” (Roberts et al., 2012)


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410
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411 3.2.6 Opportunity – social


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412 We determined high confidence for the only construct identified under this theme: social

413 influences. Participants remarked that stakeholders at all levels affected their food safety
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414 practices. Workers reported that manager presence made them conscious of food safety
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415 behaviours because they knew they were being watched. However, even though supervisors were

416 generally viewed as a facilitator towards food safety, some participants reported that managers

417 would look the other way when staff were sick or would convince workers to stay at work while

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418 ill due to the frequent need for additional staff. Food workers also stated that teamwork was an

419 essential component to helping each other stay on top of safe food handling practices.

420 “The manager observes handwashing when you return from the bathroom.” (Pragle,

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421 Harding, & Mack, 2007)

422 “We all kind of work together, tellin' each other, you know. It's, it works out pretty good.”

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423 (Abidin et al., 2014)

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424 Participants indicated that customer awareness of their practices led to improved use of food

425 safety behaviours (e.g. in open kitchens). In contrast, conflicting views were noted for the

426
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relationship of food handlers with public health inspectors.
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427 “I think there’s this dread of the inspector, yeah, and I don’t think it should be like that. It
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428 should, you know, be something you participate together in together, rather than this ‘I can

429 close you down, I’ve got the power to close you down’ ... Encouragement is better than
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430 threat.” (Taylor, 2008b)


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431
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432 3.2.7 Socio-demographic factors


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433 We identified high confidence for the influence of socio-demographic factors on food
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434 handlers’ food safety practices. In some studies, participants from diverse cultural backgrounds

435 stated that food safety standards were lower in their country of origin, which presented unique

436 challenges for operators who immigrated and started their businesses in English-speaking

437 nations. Several studies also reported that language was a barrier among food handlers, with

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438 difficulty in communication being noted between managers and staff, as well as between health

439 inspectors and operators.

440 “Much stricter here than in China. More things that we have to do to keep businesses

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441 running like licences.” (Brough et al., 2016)

442 “If [the health inspectors] write down the violations, I don’t know what they are talking

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443 about in the report.” (Liu & Kwon, 2013)

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444 Food handler age and experience was also noted to be an important determinant of food

445 safety behaviours. Some participants reported that younger, more inexperienced food handlers

446
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often skipped recommended food safety practices despite being trained in them. Participants also
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447 stated that younger food handlers would complete tasks too quickly, suggesting a possible trade-
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448 off between food safety and completing tasks faster.

449 “Just the young ones seem they just haven’t gotten it. They’ve been trained and everything
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450 else, it just hasn’t gotten into their system of naturally doing it.” (Arendt et al., 2014)
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451 On the other hand, some participants indicated that greater experience was associated with
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452 some unsafe food safety practices, such as determining the doneness of cooking using senses

453 rather than a thermometer.


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454 “They gave me [a thermometer] for barbequing chicken. But I know when things are done
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455 because I’ve been cooking for 10 years. This is a stupid rule that turns people into robots.”

456 (Niode, Bruhn, & Simonne, 2011)

457

458 4. Discussion

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459 We used systematic review methodology to identify, critically appraise and synthesize the

460 primary qualitative research studies to summarize the finding on the determinants of safe food

461 handling among food handlers at the retail and food service levels. Most of the research (70%)

462 was conducted in the US and United Kingdom (UK), which indicates a gap in qualitative

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463 research on this topic in other nations. Moreover, we identified a shortage of qualitative research

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464 on specific groups of food workers (e.g. immigrant food operators, culturally and linguistically

465 diverse food handlers) who may have unique needs, barriers, stressors, and other behavioural

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466 influences.

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467 Most of the quality assessment criteria were met by studies with some exceptions (Table
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468 1). Only one-third of studies sufficiently reported their method of analysis, which raises

469 uncertainty about whether the findings were accurately supported by the data. Studies not
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470 reporting the approach used, justifying their qualitative method, or how they generated codes

471 were categorized as not meeting this criterion (Walsh et al., 2006). Only a little more than half of
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472 the studies (56%) showed evidence of researcher reflexivity, making it difficult to determine if
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473 researchers had considered their role and influence during data collection, recruitment of

474 participants, choice of location, or how they responded to events during the study. This results in
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475 the reader being unable to sense how the researcher shaped the study or potentially influenced
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476 the project's findings (Walsh et al., 2006). Finally, only 61% of studies reported that ethical
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477 issues were considered (e.g. stated that the study was approved by an institutional ethics board).

478 Researchers undergoing future qualitative research in this area should aim to follow

479 recommended reporting guidelines, such as the Standards for Reporting Qualitative Research

480 (SRQR), to enhance trustworthiness and transparency of their results for readers (O’Brien,

481 Harris, Beckman, Reed, & Cook, 2014).

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482 The structured thematic synthesis approach used in this review has identified across-study

483 themes of factors that influence food handlers’ safe food handling practices. We used the TDF to

484 categorize these themes into specific domains that represent different cognitive, psychosocial,

485 and environmental influencers of behaviour (Cane et al., 2012). The TDF is not a theory, but a

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486 framework for categorizing the different factors that influence behaviour (Cane et al., 2012). In

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487 contrast, the COM-B model of the BCW can be used as a theory to investigate the relationships

488 of the different predictors of an individual’s behaviour in an effort to guide behaviour change

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489 (Michie et al., 2011). We linked the TDF domains to the COM-B model so that the results of this

490 review could be used as a theoretical framework to inform future primary research aiming to

491
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explain food handlers’ safe food handling practices and to inform the development of new
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492 interventions aimed at achieving behaviour change in this population.
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493 Overall, food handlers across studies demonstrated that they had good physical (e.g. skills)

494 and psychological (e.g. knowledge) capabilities. Most participants viewed training to be
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495 beneficial, but wanted it to be practical, engaging, and to also emphasize why they needed to
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496 perform certain food safety actions instead of simply explaining the correct food safety practices.

497 Future intervention designers should aim to base their training programs on a theoretical
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498 framework grounded in an appropriate behaviour change theory (e.g. Health Belief Model,
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499 Theory of Planned Behaviour, Social Cognitive Theory) for effective food safety education
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500 (Fraser & Miller, 2014; Soon, Baines, & Seaman, 2012). Additionally, incorporating an adult

501 learning theory (e.g. Transformative Learning Theory) is also suggested because most program

502 participants are expected to be adults, and it would facilitate training and education to be

503 collaborative (vs. didactic), thereby addressing the need for more equality between the trainer

504 and food handler (Fraser & Miller, 2014).

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505 Our findings also revealed some food handler knowledge deficiencies; for example, on

506 risks of foodborne illness and beliefs that it is appropriate to use sensory judgements to

507 determine if foods have spoiled or are adequately cooked. This corresponds with previous

508 surveys which have reported varying food safety knowledge scores and identified gaps among

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509 food handlers (Lee, Abdul Halim, Thong, & Chai, 2017; Manes, Liu, & Dworkin, 2012; Pichler,

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510 Ziegler, Aldrian, & Allerberger, 2014; Santos, Nogueira, Patarata, & Mayan, 2008; Soares,

511 Almeida, Cerqueira, Carvalho, & Nunes, 2012; Walker, Pritchard, & Forsythe, 2003). For

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512 example, a previous survey of over 400 food handlers in the UK reported that more than half of

513 the participants believed they could use their senses (sight, smell, or taste checks) to determine if

514
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foods were contaminated or unsafe to eat (Walker et al., 2003). These knowledge gaps should be
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515 targeted by food safety education and training initiatives for food handlers.
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516 Opportunity was divided into two categories: physical (environmental context and

517 resources) and psychological (social influences). Participants exhibited varying psychological
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518 opportunities and poor physical opportunities, preventing them from performing safe food
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519 handling behaviours. Food handlers indicated workplace policies and management as

520 determinants of safe food handling. Previous studies have demonstrated differences in food
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521 handling behaviours and attitudes among food handlers depending on various workplace
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522 characteristics (e.g. corporate-managed vs. independent ownership) (Faour-Klingbeil, Kuri, &
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523 Todd, 2015) and policies (e.g. policy requiring workers to report illnesses) (Abidin, Arendt, &

524 Strohbehn, 2013; Sumner et al., 2011). Food workers in this review reported having limited

525 space, funding, time, and poor accessibility to handwashing stations. Previous quantitative

526 surveys have produced similar findings revealing that time constraints; space; inconveniently

527 located facilities and instruments (e.g. sinks, thermometers); and inadequate resources were

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528 barriers to employees' ability to perform correct food safety practices (Abidin et al., 2013; Aziz

529 & Dahan, 2013; York, Brannon, Roberts, Shanklin, & Howells, 2009). Thus, developing training

530 programs with consideration to environmental constraints (e.g. emphasizing regular maintenance

531 and cleanliness of handwashing facilities, and keeping supplies well-equipped), and workplace

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532 culture (e.g. strong food safety values from managers, owners and/or corporate) may lead to

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533 more effective behaviour change interventions.

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534 Social influences were facilitators toward safe food handling behaviours except when

535 participants felt supervisors did not care about safe food preparation or encouraged unsafe

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536 behaviours (e.g. convincing staff to work while ill). These findings are supported by other
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537 studies (Clayton & Griffith, 2008; Howells et al., 2008), demonstrating that future programs

538 should involve both managers and coworkers during delivery of training and that workplace food
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539 safety culture is easily eroded when policies and principles are not uniformly implemented and

540 upheld by managers.


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541 Most participants provided statements indicating that automatic motivation (e.g.

542 reinforcement) and reflective motivation (e.g. intentions) influenced safe food handling
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543 behaviours. For example, the bad habits that were often practised at home by food handlers were

544 considered difficult to overcome or change when at work. Young & Waddell (2016) found that
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545 consumers often engaged in unsafe food handling practices at home, and these practices were
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546 influenced by what they had learned while growing up. Our findings confirm those in the

547 previous review among consumers suggesting that interventions may need to overcome an

548 additional hurdle - eliminating previously established poor habits among food handlers while

549 also introducing and reinforcing safe food handling practices.

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550 Food handlers indicated that they often forget to execute safe practices because of a

551 multitude of reasons, such as distractions. This could be due to lack of cues and reminders in the

552 work environment. Many participants stated that reinforcement in the form of managerial

553 support, signage, guidelines, and reward incentives were facilitators toward effective food safety

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554 practices. A previous study showed improvements in food safety practices after implementing

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555 food safety infosheets in highly visible locations in the workplace (Chapman, Eversley, Fillion,

556 Maclaurin, & Powell, 2010). Others have found that providing training based solely on

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557 improving knowledge is insufficient in affecting behaviour change (York et al., 2009). Hence,

558 food premises should incorporate reinforcement strategies along with food safety training to

559
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enhance the consistent use of desired food safety behaviours.
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560 Managers and employees expressed emotions such as pride, stress, and concern about
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561 foodborne illness. The results align with earlier studies showing that food handlers are aware of

562 their role in food safety (Bertin, Rezende, Sigulem, & Morais, 2009; Clayton, Griffith, Price, &
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563 Peters, 2002), experience feelings of anxiety during food handling (Bertin et al., 2009; Da
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564 Cunha, Cipullo, Stedefeldt, & De Rosso, 2015), and that workers with poor food safety

565 knowledge and training have greater levels of stress and anxiety (Da Cunha et al., 2015). Thus,
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566 participation in training with the goal of improving food safety knowledge and self-efficacy may
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567 assist in reducing negative feelings.


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568 Our findings revealed that participants typically showed positive beliefs about capabilities

569 and consequences. Previous quantitative studies have also shown that greater self-efficacy and

570 attitudes toward food safety are positively related to engagement in food safety behaviours

571 (Angolo, 2011; Aziz & Dahan, 2013; Clayton & Griffith, 2008; Kouabenan & Ngueutsa, 2016).

572 One exception to this was with respect to the use of gloves, which has been reported in

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573 observational studies to be poor among food handlers (Lee et al., 2017). In agreement with this,

574 our findings illustrated harmful perceptions towards the proper use of gloves or the use of gloves

575 at all. This suggests that future research into this barrier is needed to investigate how to improve

576 glove use behaviours in retail and food service settings.

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577 We found that food handlers often reported a general lack of motivation to perform safe

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578 food handling behaviours. According to a study by Ellis, Arendt, Strohbehn, Meyer, & Paez

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579 (2010), food service employees had higher internal motivations (e.g. pride, satisfaction when

580 following safe practices) compared to external motivations (communication, reward-punishment,

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581 and resources), indicating a need to improve food handlers’ external motivations through
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582 changes in the work environment and culture of the establishment. Clayton & Griffith (2008)

583 also found that the food safety practices of supervisors and coworkers in the kitchen affected
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584 employees' intentions to carry out hand hygiene actions. This is in agreement with participants'

585 statements in this review citing external factors such as a lack of management support and
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586 policies encouraging food safety behaviours for their lack of motivation.
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587 We identified socio-demographic factors, specifically experience and cultural background,


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588 as determinants of food safety behaviours among food handlers, which is not an explicit domain

589 of the TDF or COM-B model. Most food handlers recognized food service experience was a
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590 facilitator for following food safety practices, and that younger food handlers tended to rush and
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591 skip recommended practices due to their lack of experience in the food service industry. Some

592 quantitative studies have reported that food workers with greater experience have higher levels

593 of food safety knowledge (Brannon, York, Roberts, Shanklin, & Howells, 2009; Lee et al., 2017;

594 McIntyre, Vallaster, Wilcott, Henderson, & Kosatsky, 2013; Osaili, Obeidat, Hajeer, & Al-

595 Nabulsi, 2017). However, previous surveys have also found conflicting evidence on whether

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596 experience is associated with food safety behaviours (Angelillo, Viggiani, Rizzo, & Bianco,

597 2000; Brown et al., 2016; Lee et al., 2017; Sharif, Obaidat, & Al-Dalalah, 2013). Increasing

598 levels of experience may be related to stronger habits that are difficult to change (e.g. not

599 checking doneness temperatures with a thermometer). Therefore, periodic food safety training is

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600 justified for food handlers regardless of their experience. While gender was not discussed as a

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601 possible predictor of safe food handling in the qualitative studies captured in this review,

602 previous quantitative research has shown that it may also be an important factor that can

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603 influence these behaviours (Carpenter et al., 2013; Sumner et al., 2011).

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604 Some studies identified that language and communication were food safety barriers for
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605 culturally and linguistically diverse food handlers. These difficulties have been demonstrated in

606 studies comparing health inspection data between ethnic and non-ethnic independent restaurants,
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607 which revealed that ethnic restaurants had a significantly greater number of food safety

608 violations (Kwon, Roberts, Shanklin, Liu, & Yen, 2010; Liu & Lee, 2016). Offering training,
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609 inspection booklets, and other information in multiple languages may help overcome this barrier
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610 (Fraser & Miller, 2014). Furthermore, customized training sessions (e.g. using ethnic dishes as

611 examples) may help workers to recognize and relate to the content to a greater degree and
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612 therefore enhance training effectiveness to improve food safety behaviours (Niode et al., 2011).
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613 Some limitations are recognized in this study. There is a possibility that some relevant
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614 articles may not have been captured through the search strategy due to inherent variability in

615 indexing of qualitative articles (Evans, 2002). We minimized this as much as possible by

616 searching across many databases; consulting with a librarian on the search terms; performing

617 Google searches to identify any additional articles or other grey literature; and hand searching

618 the reference lists of identified relevant articles. Due to lack of qualitative research in some

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619 countries, we cannot be certain whether country-specific differences exist. However, no

620 differences were found for the countries that were included in this review. Another limitation

621 was subjectivity in coding as well as the confidence assessment. This was minimized by using

622 standardized processes, and having two reviewers complete each step. Although all identified

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623 relevant articles were in English, there is the possibility of language bias associated with an

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624 inability to identify articles published in languages other than English, French, or Spanish.

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625

626 5. Conclusion

627
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The aim of this review was to provide a qualitative synthesis of all empirical findings on
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628 the determinants of safe food handling among food handlers at the retail and food service levels
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629 using structured and transparent knowledge synthesis methods. Available research suggests that

630 food handlers were confident in their ability to serve safe food; experienced issues with
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631 motivation to perform correct practices; had some gaps in food safety knowledge; were affected
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632 by environmental stressors (e.g. time, space); and voiced a need for cues and reminders in the

633 work setting. Additionally, communication and language barriers were described in studies with
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634 culturally diverse food handlers. It was also noted that good workplace policies and work culture

635 encouraged food safety, and co-workers and managers positively shaped safe food handling
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636 behaviours; however, a lack of consistent food safety leadership by management quickly eroded
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637 this culture. Some recommendations for future educational interventions include: targeting

638 barriers through a multi-faceted approach; making training more collaborative, periodic, and

639 grounded in behaviour change and adult learning theories; overcoming environmental

640 constraints; reducing negative feelings of food handlers; and developing effective cues and

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641 reminders to be used in these settings. Qualitative studies in culturally diverse groups (e.g.

642 immigrant food handlers) were lacking; further research is warranted in this area.

643

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644 Acknowledgements

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645 The authors would like to thank the Ryerson Interlibrary Loan staff for assistance procuring

646 relevant articles and Cecile Farnum for assistance developing the search strategy. This research

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647 has been supported by a Scholarly, Research and Creative Activity Seed Grant, Faculty of

648 Community Services, Ryerson University.

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649 Conflicts of interest: none

650
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651 References
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874 180–197. http://doi.org/10.1080/15378020902910777
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M

878

879
D
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RI
U SC
AN
M

880
D

881 Fig. 1. Flow chart of relevant citations of qualitative studies included in this review.
TE

882

883 Table 1
EP

884 Characteristics of 26 relevant qualitative studies (28 articles) that investigated determinants of
885 safe food handling behaviours among food handlers at retail and food service.

Characteristic N %
C

Document typea:
Journal article 22 78.6
AC

Thesis 6 21.4
Study countryb:
USA 14 53.8
UK 6 23.1
Australia 1 3.8
Brazil 1 3.8
Kenya 1 3.8
Madagascar 1 3.8

37
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Slovenia 1 3.8
Taiwan 1 3.8
Qualitative methodology usedb:
Case study 3 11.5
Anthropology 1 3.8
Not specified 22 84.6

PT
Qualitative data collection methodsb,c:
Interviews 16 61.5
Focus groups 9 34.6

RI
Document analysis 2 7.7
Questionnaire with open-ended questions 2 7.7
Participant observation 1 3.8

SC
Theories of behaviour change used to inform the studyb,c:
Expectancy Theory 2 7.7
Awareness-to-Adherence Model 1 3.8
1 3.8

U
Conceptual Change Model
Leadership theories 1 3.8
AN
Social Cognitive Theory 1 3.8
Social Ecological Model 1 3.8
Theory of Planned Behaviour/Reasoned Action 1 3.8
Transformational Learning Theory 1 3.8
M

None reported 21 80.8


Method of participant recruitment specifiedb:
Yes 21 80.8
D

No 5 19.2
Types of food premises investigatedb,c:
TE

Restaurants 14 53.8
Caterers 5 19.2
Healthcare institutions 4 15.4
EP

Schools, colleges, and universities 4 15.4


Food processors and manufacturersd 4 15.4
Bakeries 3 11.5
C

Grocery stores, delis, butcher shops 3 11.5


Lodging facilities 2 7.7
AC

Not specified 8 30.8


Types of food handlers investigatedb,c:
Managers and chefs 17 65.4
Employees 12 46.2
Hospitality management students 3 11.5
Study targeted specific cultural or ethnic groups of food handlersb:
Yes 3 11.5
No 23 88.5
Quality assessment criteria met by each article (yes vs. no)a:

38
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Clear statement of research aims 28 100.0


Research design and data collection strategy clearly described and 25 89.3
appropriate to address the research aims
Sampling strategy clearly described and appropriate to address the 23 82.1
research aims
Method of analysis clearly described and appropriate to address the 9 32.1
research aims

PT
Findings clearly described and supported by sufficient evidence 26 92.9
Evidence of researcher reflexivity 15 53.6
Ethical issues taken into consideration 17 60.7

RI
Evidence of study relevance and transferability 24 85.7
a
886 These questions were calculated out of the total number of relevant articles (n=28).
b
887 These questions were calculated out of the total number of relevant studies (n=26).

SC
c
888 Multiple selections were possible for these questions, so answers may not add to 100%.
d
889 These types of premises were not the focus on this review, but some studies included them in
890 addition to retail and food service establishments.

U
891 AN
892 Table 2
893 Summary of the overall confidence in each identified theoretical construct using the CERQual
894 approach.
M

Finding Overall confidence


Capability - physical
Skills (training) High: finding is supported by 21 studies with rich data, minor
D

coherence concerns, and minor methodological concerns


Capability -
TE

psychological
Knowledge High: finding is supported by 24 studies with rich data, and minor
methodological concerns
Memory, attention and Moderate: finding is supported by 20 studies with limited data
EP

decision processes richness, and minor methodological concerns


Motivation - automatic
Behavioural regulation Moderate: finding is supported by 13 studies with limited data
C

richness, and minor methodological concerns


Emotion Moderate: finding is supported by 17 studies with limited data
AC

richness, and minor methodological concerns


Reinforcement High: finding is supported by 25 studies with rich data, and minor
methodological concerns
Motivation – reflective
Beliefs about High: finding is supported by 19 studies with rich data, minor
capabilities coherence concerns, and minor methodological concerns
Beliefs about High: finding is supported by 26 studies with rich data, minor
consequences relevance concerns, minor coherence concerns, and minor
methodological concerns
Intentions High: finding is supported by 22 studies with rich data, and minor

39
ACCEPTED MANUSCRIPT

methodological concerns
Social-professional role High: finding is supported by 25 studies with rich data, minor
and identity relevance concerns, and minor methodological concerns
Opportunity - physical
Environmental context High: finding is supported by 26 studies with rich data, minor
and resources relevance concerns, minor coherence concerns, and minor
methodological concerns

PT
Opportunity - social
Social influences High: finding is supported by 23 studies with rich data, minor
relevance concerns, minor coherence concerns and minor

RI
methodological concerns
Socio-demographic
factors

SC
Socio-demographic Moderate: finding is supported by 15 studies with rich data, minor
factors coherence concerns, and minor methodological concerns
895

U
AN
M
D
TE
C EP
AC

40
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Table 1
Characteristics of 26 relevant qualitative studies (28 articles) that investigated determinants of
safe food handling behaviours among food handlers at retail and food service.

Characteristic N %
Document typea:

PT
Journal article 22 78.6
Thesis 6 21.4
Study countryb:
14 53.8

RI
USA
UK 6 23.1
Australia 1 3.8

SC
Brazil 1 3.8
Kenya 1 3.8
Madagascar 1 3.8
Slovenia 1 3.8

U
Taiwan 1 3.8
Qualitative methodology usedb:
AN
Case study 3 11.5
Anthropology 1 3.8
Not specified 22 84.6
M

Qualitative data collection methodsb,c:


Interviews 16 61.5
Focus groups 9 34.6
D

Document analysis 2 7.7


Questionnaire with open-ended questions 2 7.7
TE

Participant observation 1 3.8


Theories of behaviour change used to inform the studyb,c:
Expectancy Theory 2 7.7
EP

Awareness-to-Adherence Model 1 3.8


Conceptual Change Model 1 3.8
Leadership theories 1 3.8
C

Social Cognitive Theory 1 3.8


Social Ecological Model 1 3.8
AC

Theory of Planned Behaviour/Reasoned Action 1 3.8


Transformational Learning Theory 1 3.8
None reported 21 80.8
Method of participant recruitment specifiedb:
Yes 21 80.8
No 5 19.2
Types of food premises investigatedb,c:
Restaurants 14 53.8
Caterers 5 19.2
ACCEPTED MANUSCRIPT

Healthcare institutions 4 15.4


Schools, colleges, and universities 4 15.4
d
Food processors and manufacturers 4 15.4
Bakeries 3 11.5
Grocery stores, delis, butcher shops 3 11.5
Lodging facilities 2 7.7

PT
Not specified 8 30.8
Types of food handlers investigatedb,c:
Managers and chefs 17 65.4

RI
Employees 12 46.2
Hospitality management students 3 11.5
b
Study targeted specific cultural or ethnic groups of food handlers :

SC
Yes 3 11.5
No 23 88.5
a
Quality assessment criteria met by each article (yes vs. no) :
28 100.0

U
Clear statement of research aims
Research design and data collection strategy clearly described and 25 89.3
AN
appropriate to address the research aims
Sampling strategy clearly described and appropriate to address the 23 82.1
research aims
Method of analysis clearly described and appropriate to address the 9 32.1
M

research aims
Findings clearly described and supported by sufficient evidence 26 92.9
Evidence of researcher reflexivity 15 53.6
D

Ethical issues taken into consideration 17 60.7


Evidence of study relevance and transferability 24 85.7
TE

a
These questions were calculated out of the total number of relevant articles (n=28).
b
These questions were calculated out of the total number of relevant studies (n=26).
c
Multiple selections were possible for these questions, so answers may not add to 100%.
d
These types of premises were not the focus on this review, but some studies included them in
EP

addition to retail and food service establishments.


C
AC
ACCEPTED MANUSCRIPT

Table 2
Summary of the overall confidence in each identified theoretical construct using the CERQual
approach.

Finding Overall confidence


Capability - physical
Skills (training) High: finding is supported by 21 studies with rich data, minor

PT
coherence concerns, and minor methodological concerns
Capability -
psychological

RI
Knowledge High: finding is supported by 24 studies with rich data, and minor
methodological concerns
Memory, attention and Moderate: finding is supported by 20 studies with limited data

SC
decision processes richness, and minor methodological concerns
Motivation - automatic
Behavioural regulation Moderate: finding is supported by 13 studies with limited data
richness, and minor methodological concerns

U
Emotion Moderate: finding is supported by 17 studies with limited data
richness, and minor methodological concerns
AN
Reinforcement High: finding is supported by 25 studies with rich data, and minor
methodological concerns
Motivation – reflective
M

Beliefs about High: finding is supported by 19 studies with rich data, minor
capabilities coherence concerns, and minor methodological concerns
Beliefs about High: finding is supported by 26 studies with rich data, minor
D

consequences relevance concerns, minor coherence concerns, and minor


methodological concerns
Intentions High: finding is supported by 22 studies with rich data, and minor
TE

methodological concerns
Social-professional role High: finding is supported by 25 studies with rich data, minor
and identity relevance concerns, and minor methodological concerns
EP

Opportunity - physical
Environmental context High: finding is supported by 26 studies with rich data, minor
and resources relevance concerns, minor coherence concerns, and minor
methodological concerns
C

Opportunity - social
Social influences High: finding is supported by 23 studies with rich data, minor
AC

relevance concerns, minor coherence concerns and minor


methodological concerns
Socio-demographic
factors
Socio-demographic Moderate: finding is supported by 15 studies with rich data, minor
factors coherence concerns, and minor methodological concerns
ACCEPTED MANUSCRIPT

Search Strategy
References = 3325 Excluded (duplicates) = 1422
• Database searches = 3160
• Google searches = 15
• Search verification = 6

PT
• Updated search = 144 Excluded (not relevant) = 1564

RI
Characterization

Unique references = 1903

SC
Screening and

Excluded = 311
Relevance

• Relevant quantitative study synthesized


in a separate review = 67

U
• Quantitative study with insufficient or
Relevant references = 339

AN
non-relevant data = 185
• Other language = 30
• Qualitative study with insufficient data

M
for analysis = 12
Quality Assessment /
Thematic Synthesis

Relevant qualitative articles = 28


• Full article not retrievable = 7
• Qualitative study not relevant to the

D
review question = 6

TE
Unique studies = 26 • Not primary research = 4
• Qualitative = 17
• Mixed-method = 9
C EP
AC