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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

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S0956-7135(18)30040-9

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JFCO 5959

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Food Control

Received Date: 14 November 2017

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Accepted Date: 29 January 2018

28 January 2018

Revised Date: Accepted Date: 29 January 2018 28 January 2018 Please cite this article as: Thaivalappil

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

safe food handling at retail and food service

Abhinand Thaivalappil *1 , Lisa Waddell 2 , Judy Greig , Richard Meldrum , and Ian Young

2

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1

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

Toronto, Ontario, Canada, M5B 2K3

2 National Microbiology Laboratory, Public Health Agency of Canada, 160 Research Lane, Suite

206, Guelph, Ontario, Canada, N1G 5B2

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

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

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

(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

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

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

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

32 conduct the review were developed a priori as part of the study protocol: a comprehensive

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.

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

37 onto the COM-B model of the Behaviour Change Wheel. A total of 13 categories of

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)

40 food handlers typically demonstrated good knowledge and had positive attitudes toward training;

41 2) environmental factors (e.g. policies, resources), reinforcement (e.g. posters, reminders),

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

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research and recommendations for policy and practice are discussed.

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

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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

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

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

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

59 while 14% were associated with foods prepared at catering and banquet facilities, although it is

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, &

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

64 handlers’ health, hygiene, and use of recommended safe food handling practices (Angelo et al.,

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.

67 Qualitative research studies provide insights into the possible factors which influence

68 workers’ food safety practices, and this can assist in guiding the development of appropriate

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,

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

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

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,

83 2012). It consists of 14 domains of theoretical constructs categorizing the possible influences on

84 behaviour (Cane et al., 2012). The framework can be used with the Behaviour Change Wheel

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

86 related behaviour change (Cane et al., 2012; Michie et al., 2011). The BCW characterizes

87 behaviour into three larger domains: Capability (an individual's psychological and physical

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

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

92 individual’s behaviour (Michie et al., 2011). The TDF, linked with the COM-B model of the

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

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qualitative primary research studies investigating the determinants of safe food handling

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

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

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

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

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

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

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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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2. Material and Methods

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2.1 Review approach

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This review was conducted following the guidelines in the Cochrane Collaboration

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handbook (Higgins & Green, 2011) and Thomas and Harden's (2008) guidelines for thematic

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synthesis. The review was reported in accordance with the “Enhancing transparency in reporting

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the synthesis of qualitative research” (ENTREQ) framework, which is a reporting guideline for

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qualitative research syntheses (Tong, Flemming, McInnes, Oliver, & Craig, 2012). A copy of the

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review protocol and forms are available as supplementary information. The review question was:

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

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

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

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

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

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

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

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

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

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

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

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

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

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2.2 Search strategy

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A comprehensive search strategy was developed, conducted on January 20, 2017, and

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updated on June 15, 2017. It was implemented in the following bibliographic databases: Scopus,

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PubMed, CAB Abstracts, Food Safety and Technology Abstracts, PsycINFO, CINAHL, Health

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and Safety Science Abstracts, Risk Abstracts, and ProQuest Dissertations and Theses. The search

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algorithm contained food safety terms (e.g. food safety, food hygiene), population terms (e.g.

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handler, restaurant, worker), behavioural determinant terms (e.g. attitude, knowledge), and

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outcome terms (e.g. behaviour, practice, qualitative). The algorithm was pre-tested using Scopus

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to ensure the efficient capture of articles.

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

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

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

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

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

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2.3 Relevance screening, data extraction, and quality assessment

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

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

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

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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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type, workers’ role, socio-demographics) investigated. The relevant articles were then critically

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appraised using a quality assessment form adapted from previously developed critical appraisal

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tools for qualitative research (Critical Appraisal Skills Programme, 2013; Walsh et al., 2006;

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Young & Waddell, 2016). The form contained eight individual quality criteria including: the

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scope and purpose of the study; study design; sampling strategy; analytic approach; clearly stated

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findings and interpretations; researcher reflexivity; ethical considerations; and study relevance

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and transferability (Walsh et al., 2006). The appraisal tool was used to identify the integrity,

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transparency, and limitations of qualitative research studies in this review (Walsh et al., 2006).

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2.4 Review management

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

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

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

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

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

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

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

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

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

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

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spreadsheets for analysis.

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2.5 Analysis

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The qualitative analysis was conducted using a modified thematic synthesis approach as

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presented by Thomas & Harden (2008). This approach was selected because it went beyond the

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content of the primary studies by allowing the authors to present new interpretations in a

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transparent way (Thomas & Harden, 2008). We reviewed each relevant article's results sections

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and independently completed line-by-line coding of food handlers' interpretations of their

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experience and the authors' interpretation of food handlers' experience, termed "first-order" and

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"second-order" interpretations, respectively. The resulting themes were called "third-order"

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interpretations.

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

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

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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

189 software (QSR International, Doncaster, Australia).

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

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

193 place in the findings. The CERQual approach is similar to the Grading of Recommendations

194 Assessment, Development, and Evaluation (GRADE) approach commonly used in systematic

195 reviews of interventions, but designed specifically for use in qualitative evidence synthesis

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).

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

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

202 question); 3) coherence (the consistency of findings across studies); and 4) adequacy of data

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

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

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

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

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

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3. Results

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3.1 Study characteristics

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

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articles were identified that represented 26 unique studies. A summary of the descriptive

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characteristics of the articles and studies is shown in Table 1. Most studies were strictly

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qualitative (vs. mixed-method) (65%), used interviews to collect qualitative data from

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participants (62%), did not specify the qualitative methodology used (85%), and did not report

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being guided by one or more established theories of behaviour change (81%). The types of food

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handlers investigated included managers, chefs, employees, and hospitality management students

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(Table 1). The most commonly investigated type of food premise was restaurants (54%). The

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median publication year of relevant articles was 2010 (range 2001-2016). The median sample

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size of the relevant studies was 31 (range 4-205). Among studies that conducted one-to-one

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

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

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was 4 (range 1-15).

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

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

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

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

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

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Figure 1

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Table 1

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3.2 Thematic analysis

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We identified 12 relevant constructs from the TDF and one additional inductive theme.

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These are shown in Table 2 organized under seven behavioural determinant categories from the

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BCW’s COM-B model. Each of these themes are described in detail below and supported with

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illustrative quotes from food handlers as reported in those studies. A summary of the CERQual

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confidence ratings for each theme is shown in Table 2. Detailed CERQual assessments and

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criteria ratings for each theme are available as supplementary information.

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Table 2

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3.2.1 Capability – physical

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

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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:

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

253 congruencies but then

254 Strohbehn, 2014)

for

a lot of other stuff, it just wasn't.” (Abidin, Arendt, &

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

256 employees. When training was not offered, participants stated that they did not feel valued by

257 management. Both managers and employees specified a need for more efficient training

258 methods:

259 “Turnover is a big issue for us, […] we have high turnover just with student employees.

260 And so I think it needs to happen, […], efficient training needs to happen earlier.”

261 (Roberts, Arendt, Strohbehn, Ellis, & Paez, 2012)

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

263 desire to give input and have a two-way communication with the trainer; citing a need to

264 customize training as different groups have different needs and prefer to learn in different ways;

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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3.2.2 Capability – psychological

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

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

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

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

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

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

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temperature control.

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“I thought that because I was wearing gloves I did not need to wash my hands because I am

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already covering them.” (Arendt, Strohbehn, & Jun, 2015)

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Some participants were unfamiliar with hazard analysis and critical control point (HACCP)

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systems, whereas most managers acknowledged that they did not know the full scope or benefits

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of HACCP. Some staff also seemed to be unaware of the risks of foodborne illness in the food

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they were preparing, and some reported using their senses (e.g. smell, taste, sight) to determine

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whether food had gone bad or was done cooking.

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“No, I think more the risk is in some cases like with E. coli, Staphylococcus, but it doesn’t

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affect restaurants. I don’t think restaurants are particularly bad. Its retail I think, [retail],

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

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

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

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

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

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

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

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

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3.2.3 Motivation – automatic

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This theme represented three TDF constructs: behavioural regulation; emotion; and

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reinforcement. Regarding the former, we found high confidence in the importance of habits,

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which participants reported were hard to break once they were formed. It was noted that food

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handlers often bring bad habits from home; thus, participants indicated that new food handlers

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should aim to build correct habits when they first enter the industry. Participants stated that once

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a good habit was formed, it became second nature.

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“[It’s about] making sure no one gets food poisoning – we just go through a routine, once

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you get it, everything follows.” (Brough, Davies, & Johnstone, 2016)

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We found high confidence in the construct of reinforcement. Having detailed food safety

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procedures, reward-based systems, guidelines, posters, signs, and consequences (e.g. fines,

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

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

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

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

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

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

 

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inconsistent.

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“The chance to do something different and actually get a formal qualification

they

were

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

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a certificate for it

it

just shows that they're good at what they do.” (Mortlock, 2002)

 

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

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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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finding. Most of the emotions expressed by participants related to fear, worry, and pride. Fear

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and worry stemmed from not wanting to make customers sick, lose their job, and negatively

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affect their reputation and business.

 

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"I was always worrying, I still worry a bit about eggs, you know, if the dates on them’s off,

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I will throw them away." (Taylor, 2008b)

 

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

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food handling behaviours. Some emotions were seen as barriers to food safety, such as stress,

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pressure, frustration, and apathy from staff and management.

 

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

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

 

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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

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.

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

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

341 difficult to understand.

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

344 we just constantly wash our hands. Besides, they [gloves] melt.” (Torres, 2013)

345 “I can’t do HACCP, I don’t know enough about food microbiology and advanced stuff like

346 that.” (Gilling et al., 2001)

347 Regarding beliefs about consequences, most food handlers followed safe practices because

348 they did not want their customers to contract foodborne illnesses, and to avoid being

349 reprimanded by their superiors. However, some managers stated that implementing HACCP or

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

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.

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

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

362 HACCP was an additional burden. Some participants admitted that they were only motivated

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.

365 “Sure, everyone takes those shortcuts, I’m sure it happens every single day if the laziness

366 kicks in, that’s where they’re saving time or skipping steps.” (Torres, 2013)

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

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

371 aware that they were seen as role models for food safety and that their actions would influence

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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3.2.5 Opportunity – physical

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

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

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

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

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

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consistency in enforcing food safety policies negatively affected their behaviours.

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“I kinda feel like the upper management doesn’t always like enforce everything and so, me

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going in and saying, “Don’t drink that pop when you’re cooking food,” that’s like nothing

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because the upper management walks by and gives ‘em pop or whatever, you know. To

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me, I kinda like feel like I’m, it’s not really effective because it’s not consistent across the

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board.” (Roberts et al., 2012)

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

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

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noted to create additional pressures and food safety lapses due to being understaffed.

392

Understaffed situations also created a crossover of responsibilities (e.g. cleaning bathrooms and

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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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

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

403

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

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

406

courses. We haven’t got the funds to do that, and we can’t spare the people.” (Gilling et al.,

407

2001)

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)

410

411

3.2.6 Opportunity – social

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

414

practices. Workers reported that manager presence made them conscious of food safety

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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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,

421

Harding, & Mack, 2007)

422

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

423

(Abidin et al., 2014)

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

relationship of food handlers with public health inspectors.

427

“I think there’s this dread of the inspector, yeah, and I don’t think it should be like that. It

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

430

threat.” (Taylor, 2008b)

431

432

3.2.7 Socio-demographic factors

433

We identified high confidence for the influence of socio-demographic factors on food

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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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

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

443

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

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

often skipped recommended food safety practices despite being trained in them. Participants also

447

stated that younger food handlers would complete tasks too quickly, suggesting a possible trade-

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

450

else, it just hasn’t gotten into their system of naturally doing it.” (Arendt et al., 2014)

451

On the other hand, some participants indicated that greater experience was associated with

452

some unsafe food safety practices, such as determining the doneness of cooking using senses

453

rather than a thermometer.

454

“They gave me [a thermometer] for barbequing chicken. But I know when things are done

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

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

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

466 influences.

467 Most of the quality assessment criteria were met by studies with some exceptions (Table

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

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

472 the studies (56%) showed evidence of researcher reflexivity, making it difficult to determine if

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

475 the reader being unable to sense how the researcher shaped the study or potentially influenced

476 the project's findings (Walsh et al., 2006). Finally, only 61% of studies reported that ethical

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

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

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

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 explain food handlers’ safe food handling practices and to inform the development of new

492 interventions aimed at achieving behaviour change in this population.

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

495 beneficial, but wanted it to be practical, engaging, and to also emphasize why they needed to

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

498 framework grounded in an appropriate behaviour change theory (e.g. Health Belief Model,

499 Theory of Planned Behaviour, Social Cognitive Theory) for effective food safety education

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

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

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

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

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 foods were contaminated or unsafe to eat (Walker et al., 2003). These knowledge gaps should be

515 targeted by food safety education and training initiatives for food handlers.

516 Opportunity was divided into two categories: physical (environmental context and

517 resources) and psychological (social influences). Participants exhibited varying psychological

518 opportunities and poor physical opportunities, preventing them from performing safe food

519 handling behaviours. Food handlers indicated workplace policies and management as

520 determinants of safe food handling. Previous studies have demonstrated differences in food

521 handling behaviours and attitudes among food handlers depending on various workplace

522 characteristics (e.g. corporate-managed vs. independent ownership) (Faour-Klingbeil, Kuri, &

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

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

533 more effective behaviour change interventions.

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

536 behaviours (e.g. convincing staff to work while ill). These findings are supported by other

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

539 safety culture is easily eroded when policies and principles are not uniformly implemented and

540 upheld by managers.

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

542 reinforcement) and reflective motivation (e.g. intentions) influenced safe food handling

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

545 consumers often engaged in unsafe food handling practices at home, and these practices were

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

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

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

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 enhance the consistent use of desired food safety behaviours.

560 Managers and employees expressed emotions such as pride, stress, and concern about

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, &

563 Peters, 2002), experience feelings of anxiety during food handling (Bertin et al., 2009; Da

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,

566 participation in training with the goal of improving food safety knowledge and self-efficacy may

567 assist in reducing negative feelings.

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.

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

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

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,

581 and resources), indicating a need to improve food handlers’ external motivations through

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

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

586 policies encouraging food safety behaviours for their lack of motivation.

587 We identified socio-demographic factors, specifically experience and cultural background,

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

590 facilitator for following food safety practices, and that younger food handlers tended to rush and

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

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

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

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

604 Some studies identified that language and communication were food safety barriers for

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,

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,

609 inspection booklets, and other information in multiple languages may help overcome this barrier

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

612 therefore enhance training effectiveness to improve food safety behaviours (Niode et al., 2011).

613 Some limitations are recognized in this study. There is a possibility that some relevant

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

623

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

624

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

625

626

5. Conclusion

627

The aim of this review was to provide a qualitative synthesis of all empirical findings on

628

the determinants of safe food handling among food handlers at the retail and food service levels

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

631

motivation to perform correct practices; had some gaps in food safety knowledge; were affected

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

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

636

behaviours; however, a lack of consistent food safety leadership by management quickly eroded

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

644

Acknowledgements

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

647

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

648

Community Services, Ryerson University.

649

Conflicts of interest: none

650

651

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879

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880 881 Fig. 1. Flow chart of relevant citations of qualitative studies included in this
880
881
Fig. 1. Flow chart of relevant citations of qualitative studies included in this review.
882
883
Table 1
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

%

Document type :

a

Journal article

22

78.6

Thesis

6

21.4

Study country :

b

USA

14

53.8

UK

6

23.1

Australia

1

3.8

Brazil

1

3.8

Kenya

1

3.8

Madagascar

1

3.8

ACCEPTED MANUSCRIPT

Slovenia

Taiwan

Qualitative methodology used b :

Case study

Anthropology

Not specified

Qualitative data collection methods b,c :

Interviews

Focus groups

Document analysis

Questionnaire with open-ended questions

Participant observation

Theories of behaviour change used to inform the study

b,c

:

Expectancy Theory

Awareness-to-Adherence Model

Conceptual Change Model

Leadership theories

Social Cognitive Theory

Social Ecological Model

Theory of Planned Behaviour/Reasoned Action

Transformational Learning Theory

None reported

b

Method of participant recruitment specified :

Yes

No

Types of food premises investigated

b,c

:

Restaurants

Caterers

Healthcare institutions

Schools, colleges, and universities

Food processors and manufacturers

d

Bakeries

Grocery stores, delis, butcher shops

Lodging facilities

Not specified

Types of food handlers investigated

Managers and chefs

b,c

:

Employees Hospitality management students Study targeted specific cultural or ethnic groups of food handlers b :

Yes No Quality assessment criteria met by each article (yes vs. no) a :

1

3.8

1

3.8

3

11.5

1

3.8

22

84.6

16

61.5

9

34.6

2

7.7

2

7.7

1

3.8

2

7.7

1

3.8

1

3.8

1

3.8

1

3.8

1

3.8

1

3.8

1

3.8

21

80.8

21

80.8

5

19.2

14

53.8

5

19.2

4

15.4

4

15.4

4

15.4

3

11.5

3

11.5

2

7.7

8

30.8

17

65.4

12

46.2

3

11.5

3

11.5

23

88.5

ACCEPTED MANUSCRIPT

Clear statement of research aims

28

100.0

Research design and data collection strategy clearly described and appropriate to address the research aims

25

89.3

Sampling strategy clearly described and appropriate to address the research aims

23

82.1

Method of analysis clearly described and appropriate to address the

9

32.1

research aims

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

Evidence of study relevance and transferability

24

85.7

886

a These questions were calculated out of the total number of relevant articles (n=28).

 

887

b These questions were calculated out of the total number of relevant studies (n=26).

888

c Multiple selections were possible for these questions, so answers may not add to 100%.

889

d 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.

 

891

892

Table 2

893

Summary of the overall confidence in each identified theoretical construct using the CERQual

894

approach.

Finding

Overall confidence

Capability - physical

Skills (training)

High: finding is supported by 21 studies with rich data, minor

coherence concerns, and minor methodological concerns

Capability -

psychological

Knowledge

High: finding is supported by 24 studies with rich data, and minor

Memory, attention and

decision processes

Motivation - automatic

Behavioural regulation

methodological concerns

Moderate: finding is supported by 20 studies with limited data

richness, and minor methodological concerns

Moderate: finding is supported by 13 studies with limited data

richness, and minor methodological concerns

Emotion

Moderate: finding is supported by 17 studies with limited data

richness, and minor methodological concerns

Reinforcement

High: finding is supported by 25 studies with rich data, and minor

Motivation – reflective

methodological concerns

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

Intentions

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

ACCEPTED MANUSCRIPT

Social-professional role and identity Opportunity - physical Environmental context

and resources

Opportunity - social

Social influences

Socio-demographic

factors

Socio-demographic

factors

methodological concerns High: finding is supported by 25 studies with rich data, minor relevance concerns, and minor methodological concerns

High: finding is supported by 26 studies with rich data, minor

relevance concerns, minor coherence concerns, and minor

methodological concerns

High: finding is supported by 23 studies with rich data, minor

relevance concerns, minor coherence concerns and minor

methodological concerns

Moderate: finding is supported by 15 studies with rich data, minor

coherence concerns, and minor methodological concerns

895

ACCEPTED MANUSCRIPT

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 type a :

Journal article

22

78.6

Thesis

6

21.4

Study country b :

USA

14

53.8

UK

6

23.1

Australia

1

3.8

Brazil

1

3.8

Kenya

1

3.8

Madagascar

1

3.8

Slovenia

1

3.8

Taiwan

1

3.8

Qualitative methodology used b :

Case study

3

11.5

Anthropology

1

3.8

Not specified

22

84.6

Qualitative data collection methods b,c :

Interviews

16

61.5

Focus groups

9

34.6

Document analysis

2

7.7

Questionnaire with open-ended questions

2

7.7

Participant observation

1

3.8

Theories of behaviour change used to inform the study b,c :

Expectancy Theory

2

7.7

Awareness-to-Adherence Model

1

3.8

Conceptual Change Model

1

3.8

Leadership theories

1

3.8

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

None reported

21

80.8

b

Method of participant recruitment specified :

Yes No Types of food premises investigated b,c :

21

80.8

5

19.2

Restaurants

14

53.8

ACCEPTED MANUSCRIPT

Healthcare institutions Schools, colleges, and universities Food processors and manufacturers d Bakeries

Grocery stores, delis, butcher shops

Lodging facilities

Not specified

Types of food handlers investigated b,c :

Managers and chefs

Employees

Hospitality management students

Study targeted specific cultural or ethnic groups of food handlers

Yes

No

Quality assessment criteria met by each article (yes vs. no)

a

:

b

:

Clear statement of research aims

Research design and data collection strategy clearly described and

appropriate to address the research aims

Sampling strategy clearly described and appropriate to address the

research aims

Method of analysis clearly described and appropriate to address the

research aims

Findings clearly described and supported by sufficient evidence

Evidence of researcher reflexivity

Ethical issues taken into consideration

Evidence of study relevance and transferability

4

15.4

4

15.4

4

15.4

3

11.5

3

11.5

2

7.7

8

30.8

17

65.4

12

46.2

3

11.5

3

11.5

23

88.5

28

100.0

25

89.3

23

82.1

9

32.1

26

92.9

15

53.6

17

60.7

24

85.7

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

addition to retail and food service establishments.

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

coherence concerns, and minor methodological concerns

Capability -

psychological