RELATED STUDIES

FOREIGN

Food safety is defined by the FAO/WHO as the assurance that when food is consumed
in the usual manner does not cause harm to human health and wellbeing . Food safety
is of utmost concern in the twenty-first century . Food service establishments are
sources of food borne illnesses and food handlers contribute to food borne illness
outbreaks . According to WHO (1989), food handling personnel play important role in
ensuring food safety throughout the chain of food production and storage .
Mishandling and disregard of hygienic measures on the part of the food handlers may
enable pathogenic bacteria to come into contact with food and in some cases survive
and multiply in sufficient numbers to cause illness in the consumer.
Studies by FAO (1995) recorded poor knowledge, practices in food handling in the
assessment of microbial contamination of food sold by vendors . The hands of food
service employees can be vectors in the spread of food borne diseases because of poor
personal hygiene or cross-contamination. Studies point out that most outbreaks result
from improper food handling practices . Lack of basic infrastructure, lack of knowledge
of hygiene, absence of potable water, lack of proper storage facility and unsuitable
environments for food operations (such as proximity to sewers and garbage dumps) can
contribute to poor microbial quality of foods. Inadequate facilities for garbage disposal
posed further hazards . In addition poor sanitary practices in food storage, handling, and
preparation can create an environment in which bacteria and other infectious agents are
more easily transmitted. Moreover, inadequate time and temperature control and cross
contamination are responsible for food poisoning outbreaks
Poor personal hygiene frequently contributes to foodborne illness which indicates that
food handlers' knowledge and handling practices needs to be improved. Studies on the
conditions of food and drink establishments have been scanty in Ethiopia. A study
conducted among food handlers in Bahir Dar town indicated that most of them were
infected with enteric bacteria and parasites . Good personal hygiene and food handling
practices are the basis for preventing the transmission of pathogens from food handlers
to the consumers . A USA based study suggested that improper food handling practices
contribute to about 97% of food borne illnesses in food services establishments and
homes . Therefore, to reduce foodborne illnesses, it is crucial to gain an understanding
of the knowledge and practices of food handlers . Information on the food safety
knowledge and practices from Bahir Dar is limited. The aim of this study was therefore
to obtain current information on the food safety knowledge and practices of food
handlers and the sanitary conditions of food service establishments in Bahir Dar town.

A cross-sectional study was conducted in May 2011 to evaluate the food safety
knowledge and practice of food handlers and assess the sanitary conditions of food and
drink establishments in Bahir Dar town.
Bahir Dar town, the capital of Amhara National Regional State, is located 565 Km away
from the capital of Ethiopia in North West direction. It is located at 11° 38' latitude and at
37 °10' East longitudes at 1810 m above sea level. The town has a total population of
256,999 and it is one of the tourist destinations in the country . In Bahir Dar rural to
urban migration is on the increase and the number of people eating outside their homes
is expected to increase which in turn demands for more food establishments.
A census was conducted to obtain the list of food and drink establishments in Bahir Dar
town and the town was divided into three zones based on the density of food and drink
establishments. A proportional sample size was determined for each zone and the food
service establishments were randomly selected from each zone using random table.
Four hundred fifty five food handlers working in hotels, cafe and restaurants cafes,
hotels and juice houses were randomly selected for the study.
Five sanitarians were recruited for data collection and supervision. Data collectors and
supervisor were oriented about the purpose of the study, the components of the
questionnaire and data quality management. A pretested, structured questionnaire was
used for data collection. The questionnaire was initially prepared in English and
translated into Amharic for data collection. The knowledge questionnaire contained
items on the source and methods of transmission of food borne pathogens and
knowledge of food handling. The questionnaire on food safety knowledge includes
seven questions. Data collectors interviewed the food handlers and observed the food
handlers while they were performing their chores to see their food handling practices
and collected information on food preparation and handling in the facilities and the
sanitary condition of the facilities. Food handlers were asked to indicate their level of
agreement to the statements. They have also collected information on the socio-
economic and demographic characteristics of the handlers. A checklist was used by
data collectors to assess the food handlers' food handling practices. Respondents were
asked to choose among the options. The scores ranged from 0 to 7 which were
converted to 100% based on the number of correct answers scored by the respondents.
A score of 50% and below was defined as poor knowledge and practice and a score
above 50% was defined as good knowledge and practice.
FOREIGN

The intervention studies included in this review used various key methods and
approaches to design and implement study activities, some of which were reported by
the authors to have contributed to or were associated with positive study results. These
methods and approaches include use of formative research, the HACCP approach, and
SBC; repeated and/or intensive exposure to messages and key practices; and
interpersonal communication with respected, influential change agents. Each of these
aspects is described next, along with, when available, aspects that the authors reported
as contributing to positive study results. Formative research. Four of the nine studies
used formative research to design the interventions. Monte et al. (1997) in Brazil
collected both qualitative and quantitative data through a rapid ethnographic
assessment, community survey, and structured observations to design the intervention,
messages, and materials; identified adoption constraints that were used to develop
motivational messages; and tested proposed behaviors through household trials. Four
food hygiene behaviors were prioritized for the trials based on specific criteria, including
the prevalence of the inappropriate practice in the community, the likely impact on
decreasing pathogenic contamination of complementary food if the behavior was
changed, and whether the behavior could be changed given culture and resources. The
ethnographic work revealed the concept of the cuidadosa, or “careful” mother and was
used in message development and intervention strategies.
FORIEGN

Warnock (2007) in Cambodia and Laos worked with local partners to develop a food
hygiene checklist tool based on WHO’s Five Keys to Safer Food messages and tested
the tool in rural communities. Village volunteers were then trained for 2 days on use of
the tool. After the training, volunteers worked in pairs to use the tool to collect formative
data in randomly selected village households in various communities. Through the
formative work, investigators identified the major food hygiene problems and designed
the intervention activities around improving problem behaviors. As another example,
Takanashi and colleagues (2013) conducted a study in Vietnam that included group
discussions with caregivers to inform selection of behaviors, channels for
communication, and development of the SBC messages. HACCP approach. Three of
the nine studies used the HACCP approach to identify key problems and critical actions
and test the application of the critical actions to reduce pathogens in complementary
food prepared by mothers or caregivers. In Islam et al. (2013) in Bangladesh, 30
mothers were assigned to an intervention group and 30 to a control group. After
identification of critical control points, three field workers trained mothers/caregivers in
the intervention group for 4 weeks in key behaviors to prevent bacterial contamination of
complementary food. Complementary food and water were tested for contamination
with pathogenic microorganisms at baseline, after the 4-week training, and 3 months
after the intervention. The baseline results demonstrated substantial contamination of
complementary food in the study population. The intervention, which involved mothers
and caregivers applying the critical actions identified through the HACCP approach,
significantly reduced fecal bacterial contamination in complementary food and water.
FORIEGN

Touré et al. (2011, 2013) in Mali also determined the effectiveness of implementation of
defined critical actions to reduce pathogenic contamination in complementary food. In
2011 researchers worked with 15 randomly selected mothers from a health center
nutrition education group in a peri-urban area of Bamako to identify key problems and
critical control points in the preparation of two common complementary Literature
Review on Effective Food Hygiene Interventions for Households in Developing
Countries 18 foods.13 Trained field staff worked with the mothers over several days to
adopt the critical actions to reduce pathogenic contamination. The results showed that
the critical actions, when followed diligently, were successful in eliminating pathogens
from the complementary food. In 2013 field workers worked with 30 mothers over a
longer period of time, 9 months, to practice adopting the actions. Results demonstrated
a statistically significant reduction in fecal coliform contamination of complementary food
between the baseline study and immediately after the training and between baseline
and 3 months after the training among mothers in the intervention group (p < 0.008),
while mothers in the control group had no reduction in fecal coliform contamination of
complementary food during the same time period. These intervention studies that
identify critical control points and key actions and test actions with potential users are
important to ensure that identified actions, when practiced as intended, do eliminate or
minimize bacterial contamination. If they do not, more observations may be necessary
to see whether critical actions are implemented as intended or whether other critical
actions need to be added to the recommended behaviors. SBC. Six of the nine studies
mentioned development of specific SBC messages and/or materials for the targeted
audiences to influence behavior change. Monte et al. in Brazil (1997) developed
messages that instructed mothers on what to do, how, and when, and included
motivators for practice, including messages related to mothers’ existing knowledge
about infant growth and well-being, and popular ideas about diarrheal disease,
dehydration, and death. The messages were developed based on the results of the
formative work noted previously. Among mothers who tried to adopt at least one
practice over 4 weeks, 53–80 percent were able to do so, while 60 percent of mothers
who tried to adopt four practices were successful. The authors reported that the results
demonstrated that their methodology (including use of rapid ethnographic assessment,
survey, structured observation, and household trials) was successful in achieving this
behavior change. The authors also noted the need to design and implement a
communication strategy, which they had not done. A communication strategy would
include, in addition to messages, information.
Novel foods
Functional foods and foods at the food-drug interface or neutraceuticals present yetanother challenge
that points to the need for food safety assurance. The structure of regulatory bodies in most countries
require good coordination between separate agenciesresponsible for regulating food on the one hand,
and drugs, on the other.The above developments have focused attention on the urgent need for an
effective foodsafety program. Food insecure populations are at greatest risk from the debilitating
andlife threatening effects of FBDs (CGIAR TAC, 2001).The Philippines has not been exempt from
the consequences of the above developments.The emergence of fast food chains in the Philippines
has led to the sourcing of local andimported raw materials. Beef for burgers and even fish served
in the larger fast food chains is imported .Food safety is a key concern in the consumption of local
salad vegetables grown in the highlands. Lettuce, which might be grown in Mindanao, is shipped to
Manila for cleaning nand cutting by a toll processor for a fast food chain. For produce going through
traditional channels, marketing usually involves several intermediaries, subjecting the commodity to
handling under variable conditions that hardly assure safety .Risks resulting from the misuse and
abuse of pesticides in such vegetables as bitter gourd, string beans and eggplant make some Filipino
consumers shy away from consuming these popular vegetables. Measures to safeguard the quality of
water used forirrigation and/or washing vegetables in some production areas are not in place.Local
producers of convenience foods are not necessarily equipped to assure food safetyin convenience
foods. The manner in which street-vended foods are prepared and servedcan easily lead to
contamination by microbial, chemical and physical hazards. At greatestrisk are consumers of such
food (WHO, 1996 a), who usually belong to the lower income brackets in developing countries .In
2002 researchers funded by the National Research Council of the Philippines identified Listeria
monocytogenes Campylobacter jejuni and yersinia enterocolitica as among the emerging
virulent food-borne bacterial pathogens (Bungay et al, 2002 as cited by Carteciano, 2004).The
Philippine experience with comfrey ( Symphytum officinale) provides a good illustration of how
popular but unfounded claims can lead to misguided use of herbs or food supplements with potentially
deleterious effects. Comfrey has been found to contain pyrrolizidine alkaloids that can obstruct blood
flow to the liver and cause serious liver damage in humans (Pin yuh, 1992; USFDA, 1998).Despite
calls for stronger national food safety control systems, the Philippine response has
been predominantly reactive and rarely preemptive. Effective monitoring and surveillance of FBDs in
developed countries have provided data for policy studies,which, in turn, have led to strengthened
national commitment of resources for food safety programs
 Food is a basic requirement of man. It is the source of nutrients and provides the

energy required for all activities of a human body, such as growth, repair of damaged

tissues, reproduction and sustenance. Food is the source of energy. The world food

requirement is directly related to population and population growth. It is imperative to

achieve the food production target and ensure the quality standard to combat hunger

and food related diseases worldwide (http://www.fao.org/trade/docs/LDC-

foodqual_en.html)

Food sanitation is a series of protocols which are designed to prevent the

contamination of food, keeping it safe to eat. Numerous nations have specific laws in

place concerning food sanitation, along with lengthy lists of recommendations from

public health agencies. The key to food sanitation is keeping food safe and clean, with

all of the handlers observing personal hygiene to avoid introducing harmful elements to

food, and complying with food sanitation recommendations concerning safe holding

temperatures for food, safe cooking temperatures, sterilization of cutting boards and

other implements, and so forth.

(http://www.wisegeek.com/what-is-food-sanitation.htm).

According to the Presidential decree No. 856 code on sanitation, whereas, the

health of the people, being of paramount importance, all efforts of public services should

be directed towards the protection and promotion of health and the advancement in the

field of sanitation in recent years, there arises the need for updating and codifying our

scattered sanitary laws to ensure that they are in keeping with modern standards of

sanitation and provide a handy reference and guide for their enforcement.
 The food products have to satisfy the stringent requirements with respect to

human safety, freedom from microbiological and physicochemical contamination,

organoleptic and nutritional quality, aesthetical appeal, total compliance within food laws

and environmental safety regulations.

One of the most important aspects of practicing food safety involves preventing

foods from becoming contaminated. Making sure foods are stored properly goes a long

way in avoiding any type of food contamination. Meat and vegetables should be placed

in airtight containers and placed in a freezer. Items such as flour, sugar, cornmeal, and

spices should also be stored in containers that provide an effective barrier to airborne

bacteria, and can be stored in pantries when not in active use.

(http://www.wisegeek.com/what-is-food-safety.html)

Food safety implies absence or acceptable and safe levels of contaminants,

adulterants, naturally occurring toxins or any other substance that may make food

injurious to health on an acute or chronic basis. It doesn't matter how delicious or

complicated your recipe is: if the food makes people sick because of improper cooking

or handling, all your efforts will be wasted. You can't tell if a food is safe to eat by how it

looks or tastes. Proper storage, cooking and handling are the only ways to ensure safe

food. Food quality can be considered as a complex characteristic of food that

determines its value or acceptability to consumers. Besides safety, quality attributes

include: nutritional value; organoleptic properties such as appearance, color, texture,

taste; and functional properties. Poor food preparation, handling, or storage can quickly

result in food being contaminated with germs and may lead to illness if the

contaminated food is eaten.

 Food sanitation and safety is a practice of keeping foods from cross-

contamination, storing perishable food at the appropriate temperature (41 degrees), and

heating food to a temperature that will inhibit bacterial growth (at least 180 degrees).

Remember bacteria is always present, trying to keep it from growing is our goal.

(http://wiki.answers.com/Q/What_is_food_sanitation_and_safety#ixzz1b1TtU5wJ).

The importance of food safety and sanitation has everything to do with

economics and survival in the business world. Businesses lose consumer’s confidence

and market share experience, economic costs and hardship, face extensive and costly

litigation, and/or may even go out of business altogether if their firm is found to be

responsible for a foodborne

outbreak.(http://wiki.answers.com/Q/The_importance_of_food_safety_and_sanitation_a

s_the_basis_for_preventing_foodborrne_illness_in_retail_food_establishment).

Food-borne diseases impose a heavy social and economic burden on

communities, affecting their economic productivity. They encompass a wide spectrum of

illnesses caused by microbes, parasites, or chemical contamination of food. Recent

trends in food production, processing, distribution, and preparation are creating an

increasing demand for food safety research in order to ensure a safer food supply

(http://www.mb.com.ph/articles/225651/food-safety-awareness-week, Copyright 2011.

Manila Bulletin).

Food safety is a scientific discipline describing handling, preparation, and storage

of food in ways that prevent food borne illness. This includes a number of routines that

should be followed to avoid potentially severe health hazards. Food can

transmit disease from person to person as well as serve as a growth medium

for bacteria that can cause food poisoning. Debates on genetic food safety include such

issues as impact of genetically modified food on health of further generations and

genetic pollution of environment, which can destroy natural biological diversity. In

developed countries there are intricate standards for food preparation, whereas

in lesser developed countries the main issue is simply the availability of adequate safe

water, which is usually a critical item. In theory food poisoning is 100% preventable.

The World Health Organization has estimated that there are 1.8 million deaths

every year due to diarrheal diseases and most of the cases of death can be attributed to

water and food contamination. Five key principles of food hygiene, according to WHO,

are to Prevent contaminating food with pathogens spreading from people, pets, and

pests, Separate raw and cooked foods to prevent contaminating the cooked foods,

Cook foods for the appropriate length of time and at the appropriate temperature to kill

pathogens, Store food at the proper temperature, Use safe water and raw materials.

Synthesis of the Review. The insights and concepts obtained from the literature is very

much related to the present study. The concepts help the researchers in the

constructions of the conceptual framework of the study particularly in the identification

of the variables; Food Sanitation Practices, Cleaning food utensils, Food display,

Cooking method, Storage, Storage containers, Disposal, Food service, Food

preparation.

This Review of the literature is applicable to the study because it shares ideas

that could help in explaining the food safety. The World Health Organization has

estimated that there are 1.8 million deaths every year due to diarrheal diseases and
most of the cases of death can be attributed to water and food contamination. Food

safety is generally defined as the assurance that food will not cause harm to the

consumer when it is prepared and/or eaten according to its intended use.

On the other hand, the cited literature differs from the present investigation in

terms of social and economic burden on the communities affecting their economic

productivity.

Conceptual Framework of the Study

The study is anchored of the concept of Florence Nightingale’s “Environmental

Theory” (1860) which emphasized greatly the role of the environment in the care of the

patient. Environment is defined as the external conditions in the influences affecting the

life of organism and capable of preventing, surprising, or contributing to disease,

accidents or deaths. Central to Nightingale’s Theory is the concept of the environmental

sanitation, It includes proper ventilation, adequate lighting, cleanliness, adequate

warmth, quite and diet. Food provides majority of the nutrients which the human body

needs to stay healthy and it is the key in keeping you and your family in good shape. It

is an undeniable fact that health comes above all things, thus food sanitation must be

taken into consideration as much as it could be.

The environmental theory of Florence nightingale (1860), serves as the

springboard of this study. It states that the environment must be properly utilized for the

patient to attain wellness and reduce mortality rate brought by nosocomial infections. It

is highlighted on her theory that sanitation plays a vital role in the healing process and
food preparation is at the top of that considering that the food we eat directly enters the

body and it rapidly affects’ body function as it is metabolized and absorbed by the body.