There is an inextricable link between nutrition, safety of food, and security of food [1
]. Unsafe food triggers a vicious food-based cycle of both foodborne diseases, especially affecting vulnerable consumers such as elderly, sick, young children, and infants. There has been a sharp increase in concern for the safety of food among the wealthy members of various societies. However, the realistic tragedy of foodborne illnesses occurs within the developing world [2
]. According to the Centers for Disease Control and Prevention (CDC) update in 2017, each year about 50 million people succumb to food-based ailments, leading to the death of an estimated 3,000 people. The World Health Organization [3
] estimates that children aged five-years and younger accounted for 40% of the foodborne ailment burden. Yet, globally the increasing awareness of foodborne illnesses as triggering significant risks to the health, social development, economic development, and safety of food continues to remain marginalized [1
Developed countries regularly launch national initiatives to educate food consumers and handlers. In developing countries, however, limited efforts are undertaken [4
]. As indicated by an increasing number of foodborne illnesses in Saudi Arabia for example. The Ministry of Health in Saudi Arabia reported 255 incidences of food borne illnesses in the country in 2011 alone, causing 2066 people to fall ill [5
]. The management of food control in the country is undertaken by the Saudi Food and Drug Authority (SFDA) and the execution of policies and procedures lies with the Saudi Arabia Standards Organisation (SASO) spanning across various committees, agencies, and administrators [7
]. Recently, within Saudi Arabia the Department of Environmental Foods and Rural Affairs (DEFRA) standards of Good Manufacturing Practices (GMP) and Hazard Analysis Critical Control Points (HACCP) have been introduced, but the application of these standards has been slow [8
]. The issues relating to the safety of food within a healthcare environment are further critical as the consumers served within the healthcare environment include individuals who have higher healthcare risk for poor consequences, or unavoidable death due to certain disease conditions or (immunology-compromising) treatments [9
]. Studies point out that the primary safety standards relating to the populations’ consumed food within the healthcare environments should be higher than the safety standards imposed within the restaurant or business environment [10
]. The avoidable mishandling of food in healthcare facilities, as well as the lack of hygiene procedures can lead to the transfer of food-based ailments from the food processing stage, packaging stage, food distributing states, to food consuming. The procedure may bring out the pathogens that contaminate the consumable food, which quickly multiply to trigger avoidable health problems [11
Ensuring the safety of healthcare-based food is one of the major challenges that must be implemented at all times within the healthcare facilities, including both the small residence-type categories as well as the food-delivering entities that cater to the homes of the elderly population to the bigger healthcare facilities [12
]. Within this scope, implementation of proper (hygienic) food preparation and handling practices for food service staff in the food establishments is vital to protect the health of the patients, staff, and other individuals from the effects of the consequences of foodborne diseases [13
]. The challenge relating to ensuring the safety of food within the healthcare facilities may differ between facilities or within facilities, neonatal-based intensive healthcare units in the elderly population-serving facilities. However, the basic reportable requirements for the implementation of good hygienic health care practices and effective management of safety of food must be equally implemented, and in relation to the (legal) requirements of the healthcare facilities must be considered as the same with other food-serving facilities [12
Food workers must have the required skills and knowledge to ensure implementation of good hygiene practices and the safety of food concepts within the healthcare facilities. Both prior food-based work experience and education are important inputs towards ensuring workers implement healthy food-based handling tasks [13
]. Additionally, trainings, designing policies, and setting standards can lessen the occurrence of food-based ailments caused by food handlers in food establishments [14
]. Thus, for maintaining and enforcing the safety of food within the healthcare facilities, it is vital to evaluate the food safety knowledge and practices of food service staff. Exploring the relationship between food safety knowledge and food safety practices of food service staff and how these may be associated with their demographic profiles may further aid in developing customized training programs. This study, therefore, attempts to assess the food safety knowledge and reported practices of food service staff in Al Madinah hospitals, Saudi Arabia, together with the influence that demographic characteristics (such as nationality, gender, age, level of education, length of service and undertaken food safety trainings) of the food service staff may have on their food safety knowledge and reported practices.
2. Materials and Methods
2.1. Questionnaire Design
To survey the food service staff in the hospitals of Al-Madinah in Saudi Arabia a closed-ended questionnaire was designed based on suitable and relevant questions from previous validated questionnaires applied in similar studies [6
]. The questionnaire on the self-completing form contained thirty-five questions, which were divided into three parts. The first part included five questions on the demographic characteristics of each participant, such as age, educational level, gender, nationality and work experience and covered two questions on food safety training. The second part involved the questions on the knowledge of the food handler, which was further subdivided into three parts. The first sub-section covered seven questions on knowledge of food poisoning, while the second sub-part included six questions on knowledge of cross-contamination. The third sub-heading contained seven questions concerning the knowledge of food storage. The third and the last part of the questionnaire consisted of eight questions covering food handlers’ practices.
The questionnaire was validated through a pilot study amongst food safety and business management professionals to verify of the questionnaire’s accuracy so as to strengthen the survey based on their feedback received. Croncbach alpha coefficient of internal consistency was used to estimate the reliability of the questionnaire. Alpha coefficient of the instrument was 0.71. Additionally, the questionnaire was first designed in English language, and then a back to back translation into Arabic was conducted. The questionnaire was later distributed manually to the foodservice employees in the 10 hospitals in the city of Al Madinah, where participation was voluntary.
2.2. Target Participants
All foodservice staff in the hospital were the target participants for this study and were approached to contribute in the research.
2.3. Data Collection
The questionnaires were distributed to 10 hospitals (MOH hospitals, other governmental sectors hospitals, and private hospitals) and responses from the staff were collected during the period, September to December 2017. Managers of each of the selected hospitals were contacted and explained the purpose of the questionnaire. A total of 163 respondents completed the entire questionnaires. Fifteen surveys were terminated as some of the employees did not want to respond to the questionnaire erroneously and others perceived that the questionnaire could consume a lot of their time when filling it in (response rate 91.5%). The participants spent about twelve to fifteen minutes filling in the questionnaire.
2.4. Data Analysis
Statistical Package for the Social Sciences (SPSS) version 24 statistical package was used to perform the quantitative analysis of the responses of the participants. The questionnaire had twenty-eight questions about food safety knowledge and practice; for each question the participants were awarded one point when they answered correctly and a zero for incorrect answers and their percentages calculated. Additionally, the knowledge portion of the survey had subsections to test the participant’s knowledge of food poisoning, cross contamination of food and food storage. Participant responses were analysed and presented using frequency distribution. For each of the knowledge sub-section and practice section, pass rates were calculated with participants who answered more than half of the questions in the section/sub section correctly attaining a pass. Mean score and standard deviation for each of the section/sub section were also analysed.
Research highlights that when data follows a skewed distribution, non-parametric analysis is the most appropriate method for analysing the data [17
]. Non-parametric tests (Chi-square (X2
), Manne-Whitney U and Kruskale-Wallis) were therefore used for the analysis. The Chi-square (X2
) test was used to compare the different demographics with the food safety knowledge and practice of the respondents to assess if there was a difference. For demographics with two independent samples, i.e. nationality, gender and food safety training, the Manne-Whitney U test was used. While the Kruskale-Wallis test was used in the case of demographics of three or more independent samples, i.e., age, education level and service experience in our survey [17
Furthermore, Spearman rho’s nonparametric correlation coefficients were computed to determine the relationship between food safety knowledge mean score and food safety practices mean scores Lastly, the effect of food safety knowledge (predictor/independent variable) on food safety practices (outcome/dependent variable) was determined using linear regression analysis.
This study assessed the food safety knowledge and practices of food service staff in Al Madinah hospitals, Saudi Arabia. The obtained results can inform the design of education and training programs, setting up of standards and policies and inspection regimes that can lead to better and safer food handling practices in healthcare settings in Saudi Arabia. Food safety efforts generally tend to focus on laboratory examination and physical investigation of the end product, while food handling and practices gets limited attention. As established in this study, food handlers in healthcare settings need effective and regular education and training to safeguard individuals with higher healthcare risk. It is therefore recommended that authorities, hospital management, researchers, educators, and food safety communicators should work towards educating and supporting the hospital food service staff to advance their food safety knowledge to safer food practices.