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Food safety knowledge and practices of nursing


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Article in Italian Journal of Food Science January 2012

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SURVEY

FOOD SAFETY KNOWLEDGE AND PRACTICES


OF NURSING STUDENTS

N. SANLIER1*, S. BILICI1, B. ELIK1 and E. MEMIS2


1
Gazi University, Faculty of Health Sciences,
Department of Nutrition and Dietetics, Besevler, Ankara, Turkey
2
Gaziosmanpasa University
Dincerler School of Tourism and Hotel Management
TOKAT/ TRKIYE
* Corresponding author: Tel. +90 312 216 26 04,
email: ntekgul@gazi.edu.tr, nevintekgul@gmail.com

Abstract

The aim of the study was to evaluate the perception of food safety knowledge of 662 nursing
students (629 females, 33 males) aged between 18 and 26. A statistically significant correlation
was found between food hygiene, personal/kitchen hygiene knowledge, food handling practices,
food safety attitudes, and total score (p<0.01). The female students food safety knowledge, per-
sonal/kitchen hygiene knowledge, food handling practices, and total scores relating to food safe-
ty scored significantly higher than those of males (p<0.01). Results strongly emphasize the need
for basic education in food safety throughout the nursing course.

- Key words: attitudes, food safety, hygiene, knowledge, nurse, practices -

Ital. J. Food Sci., vol. 24 - 2012 1


INTRODUCTION people can be exposed to infections and possible
complications; gastroenteritis can impair diges-
Food safety is a global health goal and food- tion and absorption of nutrients; and the per-
borne diseases are a major health issue (VELU- ception or fear about poor food hygiene practic-
SAMY et al., 2010). Foodborne diseases represent es might result in patients rejecting the meals
a widespread and growing public health prob- supplied by the hospital catering service (BAR-
lem, in both developed and developing coun- RIE 1996; DEREA et al., 2008).
tries. This problem, however, has more impact Further concern arises from the common use
on health and economy in developing coun- of nurses or domestic staff as food handlers, as
tries but no reliable data are available (WHO, they are not specifically trained about food hy-
2007). The major food safety risks are not eat- giene and HACCP but can be engaged in the re-
ing a healthy diet and failure to avoid foodborne ceipt, distribution and serving of readymade
diseases (CHASSY, 2010). Foodborne diseases foods and supervision of these services (BUC-
caused by microbial pathogens, biotoxins, and CHERI et al., 2007). In Turkey, owing to the
chemical contaminants in food represent seri- small number of dieticians in hospitals nurs-
ous threats to the health of thousands of mil- es are sometimes responsible for the distribu-
lions of people (FAO and WHO, 2008). It is diffi- tion and serving of meals and helping patients
cult to estimate the incidence of foodborne dis- to consume their meals properly.
eases worldwide because most cases of the dis- The prevention of foodborne diseases re-
ease cannot be recorded. Within two decades, quires all food consumers, especially nurses, to
the human population is predicted to reach 8.5 be taught about food handling practices. Prior
billion, 80% of whom are expected to be in de- to such education, however, it is important to
veloping countries (WHO, 1997). In the indus- identify the food safety issues relevant to nurs-
trialised countries up to 10% of the population es as consumers (JEVSNIK et al., 2008; OSAILI
may suffer annually from foodborne diseases et al., 2011). In addition, education about food
(WHO, 1998; KAFERSTEIN and ABDULSSAULAM, and nutrition issues at an early age influences
1999). WHO estimated that in 2005 1.8 million the attitudes of youngsters and enhances the
people worldwide died from the effects of food- knowledge and skills required for them to un-
borne diseases (WHO, 2005). It has been esti- derstand contemporary issues related to food
mated that foodborne diseases cause approx- (LYTLE, 1995).
imately 76 million illnesses, 325,000 hospital- There is no education programme in Turkey
isations and 5000 deaths in the United States for improving the food safety knowledge and
each year (MEAD and SLUTSKER, 1999). In Tur- practices of consumers in any age group or in
key, according to the Ministry of Health (2006), schools, and assessing the basic knowledge of
26,772 people were hospitalised because of food- young consumers is essential for developing ef-
borne diseases. Some 23,901 Salmonella typhii fective food safety programmes. To the best of
infections, 429 Salmonella paratyphii infections, our knowledge, limited studies focusing on nurs-
21,068 cases of dysentery and 8,824 cases of ing students have been conducted and there
hepatitis A occurred in 2004. Since the report- is no study concerning food safety knowledge
ing of foodborne diseases to a specified agency of nursing students in Turkey and the world.
is not obligatory in Turkey, data on foodborne Therefore, this study aimed at evaluating the
infections are inaccurate (WHO, 2004). perception of food safety by nursing students
and the influence of food, personal and kitchen
Institutions and professions, which are in con- hygiene and safety education on the food safe-
stant interaction with the public, are reliable re- ty knowledge, attitude and practices of nurs-
sources to persuade people to adopt desirable ing students.
habits as regards food safety. Therefore nurses
working in the health sector can be regarded as
a potential source to be used for this purpose, METHOD
which in turn makes their information level in
terms of food safety crucial for several reasons. Design, sample and data collection
The major task of public health professionals is
to deal with public awareness. As health profes- A cross-sectional study was conducted and
sionals, nurses should have appropriate knowl- the questionnaire was administered between
edge about adequate and balanced nutrition March and June 2010 to assess food safety
as well as food safety (BUCCHERI et al., 2007). knowledge, practice and attitudes of nursing
The importance of safe food for hospitalised pa- students in Ankara, the capital of Turkey. The
tients and the detrimental effect that contami- study population constituted final-year students
nated food could have on their recovery has been from five typical public universities and consist-
widely emphasised. Food safety in hospital may ed of 739 nursing students whose ages were be-
have unique features: many patients are more tween 18 and 26. A structured questionnaire
vulnerable than healthy subjects to microbio- was self-administered by 739 students in the
logical and nutritional risks; large numbers of classroom environment and 681 were returned

2 Ital. J. Food Sci., vol. 24 - 2012


Appendix Assessment of the answers.

Questions Assessment Score range

Food safety knowledge True = 1 point Food safety knowledge: 0-10 points
(10 questions) False = 0 points
Personal and kitchen hygiene Personal and kitchen hygiene:0-6 points
Knowledge (6 questions)

Food handling practice (14 questions) Always=3 Food handling practice: 14-42 points
Food safety attitude (8 questions) Sometimes=2 Food safety attitude: 8-24 points
Never=1 point

Total 22-82 points (mean = 64.246.69)

(92% return rate). After questionnaires which times 2, always 3 s. In the negative sentences,
had missing values were eliminated, analyses the grades were assigned in reverse order.
were carried out on 662 (629 95% female, 33 - The Cronbach alpha coefficient of internal
5% male) valid questionnaires. In Turkey, nurs- consistency was used to estimate the reliabili-
ing is largely perceived as a womans profession, ty of the questionnaire. An alpha coefficient of
although in recent years men have also entered 0.76 was considered to be acceptable for food
this profession. Therefore, the number of female safety knowledge.
nursing students participating in the study was A higher score represents a higher level of food
greater than the number of male nursing stu- safety, personal/kitchen hygiene knowledge,
dents. The participants were informed about the food handling practice and attitude. The ques-
subject, purpose and rules of the research. Stu- tionnaire was given to the nursing students by
dents consent was required prior to commence- the researchers in the face-to-face method and
ment of the study. Each participant signed a vol- took approximately 15 min to complete. Stu-
untary participation form and filled in the ques- dents were informed about the purpose of the
tionnaires in strict accordance with the Decla- study and the importance of the reliability of
ration of Helsinki (World Medical Association). their answers. To guarantee the anonymity of
The participants were informed about the sub- respondents and easy identification of question-
ject and the purpose of the research. naires completed by individuals, identity num-
bers were randomly assigned to each question-
INSTRUMENT naire. Items in the questionnaire were explained
when necessary and administered at one sitting
A structured questionnaire was designed to as much as possible.
collect the research data. The questionnaire was
administered to assess the food safety knowl-
edge, food safety practices and food safety beliefs STATISTICAL ANALYSIS
of the participants. The questionnaire was based
on those used in earlier studies (SAMMARCO et All statistical analyses were performed with
al., 1997; HAAPALA and PROBART, 2004; SANLI- SPSS (Statistical Package for Social Sciences)
ER, 2009). The questionnaire was pilot-tested by Version 15.0 (SPSS, Inc., Chicago, IL, USA). De-
86 participants between March and April 2010, scriptive statistics (mean and standard devia-
resulting in minor modifications to the wording. tion, or frequency) were used for all variables.
The revised questionnaire was divided into five The independent sample t test was used to as-
sections: demographic section (three questions), sess the difference between gender and age. Cor-
food safety knowledge (ten questions), personal/ relation analysis with Pearsons correlation co-
kitchen hygiene knowledge (six questions), food efficient was conducted to explore the associa-
handling practice (fourteen questions) and food tions between knowledge, practice and attitude.
safety attitude (eight questions). In all analyses, 5% significance levels were used.
The assessments of the answers were summa-
rized as in the Appendix. Answers to the ques-
tions related to food safety knowledge were grad- RESULTS
ed, one point being given for the right answer
and zero for the wrong answer. The scale (which Ninety-five per cent of participants were fe-
was related to safe food preparation practices) male and 5% were male. The mean age of the
included a set of negative sentences (Table 2, study population was 20.91.6 years (male:
statements, 1, 2, 5, 8, 10, and 11) in addition to 21.01.3 years, female: 20.91.7 years, respec-
the positive ones. Responses to the positive sen- tively) and 55.4% of them were over 20 years old.
tences were graded as follows: never 1, some- Whereas 77.2% of the participants replied

Ital. J. Food Sci., vol. 24 - 2012 3


that the statement the smell/appearance of ing foods (82.8, 83.5, and 90.5%, respective-
foods that cause food poisoning is bad was false, ly), (Table 1).
78.2% of them replied that the statement there It was found that 26.7% of the participants al-
is no objection to the use of broken or cracked ways/sometimes use dirty eggs without washing
eggs was true. Also, the majority of the partici- them carefully and 24.9% of them never touch
pants rated as true the statements eggs cooked cooked foods after handling raw foods. Sixty-
well can be kept at room temperature for more nine per cent of the participants stated that they
than two days, incorrect storage of foods does never tasted milk to test it instead of checking
not constitute a hazard and foods are hazard- the expiry date and 65.4% of them do not allow
ous that prepared with raw eggs (75.7, 84.3, raw chicken, fish and meat to come into contact
65.1%, respectively). As regards the distribu- with each other. It was also found that 62.6%
tion of participant responses relating to food and of the participants sometimes/always use out-
personal hygiene knowledge, 38.5% of the nurs- door milk after boiling it for half an hour and
ing students rated as false the statement ciga- 56.2% of them stated that they thawed frozen
rette smoke blowing into the air contaminates meat always/sometimes on countertops/radia-
food and the air with saliva, whereas 46.8% of tors. The assessment of the attitudes concern-
them rated as true the statement wiping the cut- ing food safety practices showed that 44.5% of
ting board with a disposable towel after use pre- nursing students stated it was not important
vents bacterial growth. The majority of the re- whether bought ready meals contained additives
spondents rated as true the statements bacte- or not, 59.4% of them said shopping should al-
ria passed by hands to foods will cause toxins, ways/sometimes be done at the supermarket
hands should be dried with disposable towels because their products were of higher quality,
and surfaces should be cleaned before prepar- 39.3% of them reported that sales promotions

Table 1 - Distribution of nursing students responses relating to food, personal and kitchen hygiene knowledge.

Statements True False

n (%) n (%)

Food hygiene knowledge


1. The taste, appearance and smell of foods
that cause food poisoning are bad (False) 151 (22.8) 511 (77.2)
2. There is no objection to the use of cracked
or broken eggs (False) 518 (78.2) 144 (21.8)
3. Eggs that are cooked well can be kept
at room temperature for more than 2 days (False) 501 (75.7) 161 (24.3)
4. Freezing does not kill bacteria in foods,
only stops their reproduction (True) 454 (68.6) 208 (31.4)
5. Canned foods can be stored on shelves
in the original packaging (True) 406 (61.3) 256 (38.7)
6. Foods stored incorrectly do not constitute
a health hazard (False) 558 (84.3) 104 (15.7)
7. The internal temperature of chicken and
Turkey must be high for safe cooking (True) 311 (47.0) 351 (53.0)
8. Raw eggs or foods containing raw eggs
are hazardous (True) 431 (65.1) 231 (34.9)
9. Meals suspected of being spoiled could
be consumed again after boiling (False) 528 (79.8) 134 (20.2)
10. Fruit and vegetables that can be peeled
should be washed (True) 574 (86.7) 88 (13.3)

Personal and kitchen hygiene knowledge


11. Cigarette smoke blown into the air contaminates
foods and the air with saliva (True) 407 (61.5) 255 (38.5)
12. Wiping the cutting board with a disposable towel
after use prevents bacterial growth (False) 310 (46.8) 352 (53.2)
13. Bacteria passed by hands to foods
will cause toxins (True) 548 (82.8) 114 (17.2)
14. Hands should be dried with disposable
towels (True) 553 (83.5) 109 (16.5)
15. Surfaces should be cleaned before
preparing foods (True) 599 (90.5) 63 (9.5)
16. Swabs can be used as cleaning equipment
during the preparation of foods (True) 235 (35.5) 427 (64.5)

4 Ital. J. Food Sci., vol. 24 - 2012


Table 2 - Distribution of nurses practices and attitudes related to food safety.

Always Sometimes Never

n (%) n (%) n (%)

Food handling practices


1. Keep cooked foods at room temperature
until they are cooled (-) 441 (66.6) 146 (22.1) 75 (11.3)
2. Use dirty eggs carefully without washing (-) 96 (14.5) 81 (12.2) 485 (73.3)
3. Do not touch cooked foods after handling raw foods 296 (44.7) 201 (30.4) 165 (24.9)
4. Keep raw and cooked food separate 485 (73.3) 106 (16.0) 71 (10.7)
5. Test the safety of milk by tasting instead 116 (17.5) 89 (13.4) 457 (69.0)
of checking the expiry date (-)
6. Store pasteurised milk in the refrigerator up to 3 days 362 (54.7) 177 (26.7) 123 (18.6)
7. Do not allow raw chicken, fish and meat 433 (65.4) 174 (26.3) 55 (8.3)
to touch each other
8. Taste the foods to see whether they are safe or not (-) 175 (26.4) 172 (26.0) 315 (47.6)
9. Do not freeze foods again after thawing 509 (76.9) 108 (16.3) 45 (6.8)
10. Use outdoor milk after boiling for half an hour (-) 217 (32.8) 197 (29.8) 248 (37.5)
11. Thaw frozen meat on countertops/ radiators (-) 193 (29.2) 179 (27.0) 290 (43.8)
12. Put leftover foods into the refrigerator within two hours 451 (68.1) 168 (25.4) 43 (6.5)
13. After purchasing foods that could go off in a short time 476 (71.9) 132 (19.9) 54 (8.2)
put them into the refrigerator within two hours
14. Wash poultry like chicken, turkey, etc. before cooking 564 (85.2) 68 (10.3) 30 (4.5)

Attitudes and statements on the implementation of food safety


15. It is not important whether bought ready meals 267 (40.3) 102 (15.4) 293 (44.3)
contain additives or not
16. Branded products should be purchased 135 (20.4) 251 (37.9) 276 (41.7)
17. A clean environment of places selling 632 (95.5) 15 (2.3) 15 (2.3)
18. food products is important
19. The nutrient value should be considered 390 (58.9) 180 (27.2) 92 (13.9)
rather than food taste
20. Food shopping should be done at supermarkets 102 (15.4) 291 (44.0) 269 (40.6)
that are considered to offer better quality products
21. Sales promotions have an important impact 228 (34.4) 174 (26.3) 260 (39.3)
on the decision to buy certain foods
22. Bloated cans should not be consumed 552 (83.4) 67 (10.1) 43 (6.5)
23. When purchasing products one should read 583 (88.1) 54 (8.2) 25 (3.8)
the information and instructions on packaging carefully

have an important impact on food purchasing < 0.01) and food handling practice (r = 0.484, p
decisions. The majority of the participants indi- < 0.01) and food safety attitudes (r = 0.178, p <
cated that bloated cans should not be consumed 0.01), food handling practices were found to be
(83.4%) and one should read the information positively correlated with food safety knowledge
and instructions on packaging (88.1%) (Table 2). (r = 0.550, p < 0.01) and food safety attitudes (r =
The comparison of scores according to vari- 0.249, p < 0.01), food safety attitudes were cor-
ous variables is given in Table 3. It was found related with food safety knowledge (r = 0.202, p
that the female nursing students food safe- < 0.01) and food handling practices (r=0.249, p
ty knowledge (t = -2.920, p = 0.004), person- < 0.01) and total score were correlated with all
al/kitchen hygiene knowledge (t = -3.327, p = study variables (p< 0.01) (Table 4).
0.001), food handling practices (t = -3.095, p
= 0.002), attitudes towards food safety and to-
tal scores relating to food safety (t = -3.579, p DISCUSSION
= 0.000) were significantly higher than those of
males (p < 0.05). In terms of age groups the dif- Although the public is increasingly concerned
ferences were not statistically significant (p > about food-related risks, the rise in food poison-
0.05) (Table 3). ing cases suggests that people still make deci-
As regards the correlation of food safety knowl- sions about food consumption, food storage and
edge, personal/kitchen hygiene knowledge, food food preparation that are less than ideal from
handling practice and food handling practice a health and safety perspective (MCCARTHY et
scores, the nursing students personal/kitch- al., 2007). This study investigates the percep-
en hygiene was found to be positively correlated tion of food safety by nursing students and the
with food safety knowledge score (r = 0.514, p impact of food, personal/kitchen hygiene and

Ital. J. Food Sci., vol. 24 - 2012 5


Table 3 - Comparison of scores according to various variables.

Variables Food safety Personal/kitchen Food Food safety Total


knowledge hygiene handling attitude score
knowledge practice
SD SD SD SD SD

Gender
Male (n=33) 5.762.41 3.271.35 32.613.23 18.582.00 60.216.61
Female (n=629) 6.741.86 4.041.29 34.683.78 18.981.96 64.456.64
t -2.920 -3.327 -3.095 -1.165 -3.579
p 0.004 0.001 0.002 0.245 0.000

Age (year)
20 (n=295) 6.821.78 4.021.19 34.633.52 18.891.91 64.376.18
> 20 (n=367) 6.591.99 3.991.40 34.533.97 19.012.01 64.147.09
t 1.564 0.192 0.326 -0.768 0.447
p 0.118 0.848 0.744 0.442 0.655

Table 4 - Correlation of food safety knowledge, personal/kitchen hygiene knowledge, food handling practice and food han-
dling practice scores (r).

Personal/kitchen Food handling Food safety Total


hygiene knowledge practice attitude score

Food safety knowledge 0.514** 0.550** 0.202** 0.754**


Personal/kitchen hygiene 0.484** 0.178** 0.667**
knowledge
Food handling practice 0.249** 0.888**
Food safety attitude 0.526**

**P< 0.01.

safety education on the food safety knowledge, behavioural change (BARANOWSKI et al., 2002).
attitude and practices of nursing students. The Healthcare providers are a trusted source of in-
food safety knowledge, attitude, and behaviour of formation on health care and food safety prac-
people play a major role in the incidence of food- tices. Health professions may play a substantial
borne diseases. Foodborne diseases are a wide- role in educating consumers on safe and appro-
spread public health problem all over the world priate behaviours (FEIN et al., 1995). Nurses in
and often seen in both developed and less de- particular are considered to lead the communi-
veloped countries although the incidence varies ty and are responsible for the development and
from one country to another, depending on eco- administration of education about preventative
nomic conditions and forms of social life (UNU- health services for the public.
SAN, 2007; SANLIER, 2009, 2010). In response In this study it was found that the majority of
to the increasing number of foodborne diseas- nurse consumers do not have right information
es, governments all over the world are intensi- about food, personal and kitchen hygiene (Ta-
fying their efforts to improve food safety (SUB- ble 1, Table 2). For example, they did not give
BA et al., 2007). the right answer to statements like freezing does
Foodborne diseases have been associated with not kill the bacteria but only stops their repro-
improper storage or reheating, food stored in- duction, the inner temperature of poultry while
appropriately and cross-contamination. These cooking must be high, foods prepared with raw
contributory factors result from lack of food hy- eggs have a potential risk, wiping cutting boards
giene awareness or implementation (WALKER et with disposable towels inhibits bacterial growth.
al., 2003; SANLIER 2009; SCHAFER et al., 1993). A number of studies have demonstrated a lack
International studies have found that consum- of correlation between food hygiene training and
ers often implement unsafe food-handling behav- improvements in food hygiene behaviour (ANSA-
iours during domestic food preparation. Such RI-LARI et al., 2009; SANLIER 2009; SANLIER and
malpractices need to be improved to reduce the TRKMEN 2010). In this study nursing students
risk and incidence of food poisoning (REDMOND practices and attitudes regarding food safety
and GRIFFITH, 2004; SANLIER et al., 2010). were found to be inappropriate (Table 2). Con-
Consumers need knowledge of effective food sumers true perceptions of safe food, food safe-
handling skills and then need to be motivated ty knowledge, behaviour, attitudes and practices
to act on that knowledge as preconditions to are important. The results of consumer studies

6 Ital. J. Food Sci., vol. 24 - 2012


concerning food safety knowledge and practic- of interest to food producers and retailers, pub-
es have shown that consumers are aware of and lic authorities and health educators (WILCOCKY
are thinking about food safety, although there et al., 2004; JEVSNIK et al., 2008) Nurses con-
are also many gaps in food safety knowledge and sumer education should target safe practices in
practices that could result in foodborne diseases food hygiene, causative foodborne diseases and
(BADRIE et al., 2006; RASPOR et al., 2006; JEVS- agents, food-handling concepts such as cross-
NIK et al., 2008). contamination, and the principles of HACCP,
Surveys have produced inconsistent results ISO 22000 as applied to health and food educa-
with regard to the relation between food safety tion in nursing school programmes (WHO, 2000;
behaviours and education level, some risky prac- BADRIE et al., 2006). School and university set-
tices being more common at higher levels of edu- tings would be the best places to reach young
cation and income (SHIFERAW et al., 2000; SAN- people and teach them key food safety concepts.
LIER et al., 2010). According to the studies car-
ried out in Turkey, food hygiene knowledge, at-
titude and perception scores are higher in wom- LIMITATIONS OF THE STUDY
en than men, higher in those aged 45 and old-
er, higher in health areas than social areas, and Because the population of this study consist-
college graduates have greater knowledge of food ed of nursing students from central Turkey, the
safety but lower scores at the same time (UNU- results cannot be generalized to all nurses or
SAN, 2007; SANLIER, 2009). The present study to all ages. Although the reliability coefficient
supports earlier findings (Table 3, Table 4). Stud- was found to be high, interpretation of the re-
ies have suggested that education and income sults is limited owing to responses being self-
are associated with attitudes towards food safe- reported and prone to bias by the subjects. In-
ty (BREWER and PRESTAT, 2007; STINSON et al., strument validation for all university students
2008; SUBBA et al., 2007; ZBILGEN, 2010). YAR- through more testing and observational stud-
ROW et al. (2009) stated that food safety beliefs, ies is needed.
attitudes, knowledge and practices could change
through educational intervention. SAMMARCO et
al. (1997) indicated that consumers do not have ACKNOWLEDGEMENT
enough knowledge and have improper practices
related to personal hygiene, food handling and The Authors would like to thank the participants for their
food storage and even basic and simple knowl- honest completion of the questionnaires.
edge about detergents, disinfectants and steri-
lisation is inadequate. Findings from our study
suggest that improper practices, such as using REFERENCES
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Paper received March 30, 2011 Accepted July 19, 2011

8 Ital. J. Food Sci., vol. 24 - 2012

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