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CHAPTER 1: INTRODUCTION

1.1

Study background

Food can be defined as the product that is rich in nutrients and required by
microorganisms. The major sources of contamination that food may be exposed are
from water, air, dust, equipment, sewage, insects, rodents and employees. The fact
remains that food is the source for microorganisms in which can cause illness because
of the changes in food production, handling and preparation techniques as well as
eating habits (Nee and Norrakiah, 2011). Meanwhile, definition for food safety is the
degree of confidence that food will not cause harm to the consumer when it is
prepared, served and eaten according to its intended use (Fawzi and Shama, 2009).

A major role in transmitting pathogen passively from contaminated sources


such as transmitting pathogens from raw meat to a ready to eat food is play by the
food handlers. It is because, from their hands, cuts or sores, mouth, skin and hair, they
may carry some human specific food borne pathogens like Hepatitis A, noroviruses,
typhoidal Salmonella, Staphylococcus aureus and Shigella sp (Sharif et al, 2013).
Usually, the basic rule of food preparation such as mishandling and taking for granted
hygiene practice contributed to the outbreaks of food poisoning have been neglected
by the food handlers (Onn Rashdi et al, 2009). Basically, food poisoning which is
characterized by short incubation period, acute illness and clinical symptoms of
mainly gastro-intestinal disturbances is used as synonymous for food-borne diseases or
food borne illness (Ebtisam and Madiha, 2013). According to Farisyah from Food
Institute of Malaysia in her lecture, foodborne illness can be defined as an illness from
consuming food that contains a harmful substance, harmful microorganisms or their
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toxins. In Malaysia condition, foodborne diseases in 2009 were low which is 0.14
cases per 100,000 population, but in term of food poisoning cases is on the rise as
proven by the incidence rate of 62.47 and 36.17 per 100,000 population in 2008 and
2009 respectively based on Ministry of Health, 2009;2010 (Norazmir et al, 2012)

To ensure the safety of prepared food, an entire range of issues have been
addressed and basically, the term food safety is progressively more being used in a
place of food hygiene. However, the health status of food handlers as well as their
hygiene behaviours and practices can cause the probability of food contamination. At
any point during food journey through production, processing, distribution, and
preparation, food contamination may occur (Mudey et al, 2010). The unsafe foodhandling practices can be considerable as proportion of foodborne diseases since food
safety is an international concern. Hence, in order to minimize the pathogenic
microorganisms in food, the knowledge of safety rules must be enhanced (Alrabadi et
al, 2013).
The understanding of the interaction on existing food safety beliefs, knowledge
and practices of food handlers is important in order to reduce foodborne outbreaks.
The good levels of knowledge and effective practices of knowledge towards food
safety among food handlers were essential in ensuring the safe production of food. In
addition, an attitude is also main factor besides knowledge to ensure a reduction trend
of foodborne diseases (Nee and Norrakiah, 2011). Based on study by Ko (2011), it is
reported that there are four types of relationships between knowledge, attitude, and
behavior. The first type of relationship exists where knowledge can directly influence
attitude but not directly influence behavior. The second type of relationship exists
where knowledge and attitude influence each other at the same time. The third type of
relationship exists where knowledge and attitude independently influence behavior.
The fourth type of relationship exists where knowledge shared direct and indirect
influences on behavior.
In Europe, approximately one-third of foodborne illness cases were attributed
to the home, with half or more of all Salmonella outbreaks traced to the home (Byrd
Bredbenner et al, 2013). So that, the first place that has been demonstrated considered
as the foodborne diseases develop due to poor personal and/ or environmental hygiene
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with increased risk of infection is private home setting. Apart from that, foodborne
diseases are progressively increasing and the numbers of reported cases are unable to
estimate due to the lack of outbreak reports. Thus, in order to adopt good hygiene
practices, it is required to reduce the risk of improper food handling and storage in
home setting (Langiano et al, 2012). A major source of food poisoning is a food
prepared at home where it has been identified. The food preparation practices at home
causes the percentage of food poisoning cases arises and may be especially underrepresented in outbreak statistics. There are some common mistakes identified include
serving contaminated raw food, cooking or heating food inadequately, having infected
persons handle implicated food and practice poor hygiene (Fawzi and Shama, 2009).

According to WHO (2014), high levels of morbidity and mortality is main


responsibility of food borne disease in the general population, especially at-risk
groups, such as infants and young, children, the elderly and the immunocompromised.
A common childhood illness along with other types of gastrointestinal diseases is a
food poisoning. Most of children will develop food poisoning at some point in their
childhood and it can be considered at high risk for food poisoning which can be
attributed to their underdeveloped immune systems. Compared to an adult, their
systems are not as effective at fighting off bacteria and viruses. Thus, once children
become infected, they can have a hard time getting well. In conclusion, the food
handlers in the home are a mother where their role is to ensure food safety and hygiene
for their infants and children (Ebtisam and Madiha, 2013). For

the

overall,

the

foodborne illness outbreaks in Malaysia, the causes are unhygienic food handling
practices and the inadequacy of a safe water supply besides poor environmental
sanitation (Nee and Norrakiah, 2011).

1.2

Problem statement

The previous study by Ebtisam and Madiha (2013) reported a significant proportion of
food borne illnesses arises from practices in the home kitchen. In order to reduce food
hazards, the information are needed about how food becomes unsafe at home and
about what changes in environmental conditions, beliefs and behaviour must be
accomplished. Many people are poisoned in less developed countries because of the
consumption of foods produced under unhygienic conditions, lack of hygiene
education, contaminated waters, inappropriate food storage conditions, lack of
cleaning and pesticide residue. Apart from that, there are three important factors
playing major role in the incidence of food poisoning especially with regard to food
handlers which are knowledge, attitude and practices (KAP). Besides that, according
to Mizanur et al (2012), the study stated that World Health Organization (WHO) has
developed five main keys to safer food in which the keys are keeping clean, separating
raw and cooked food, cooking thoroughly, keeping food at safe temperatures, and
using safe water and raw materials.
Based on Byrd- Bredbenner et al (2013), the study stated that the experts agree
the primary location where foodborne outbreaks occur is at the home. However, many
consumers do not believe the home to be a risky place. The reasons why home is the
risky location associated with significant foodborne illness risk are since the greatest
proportion of the food we eat is prepared at home, so it increasing the opportunities for
food handling errors to occur. In addition, many consumers do not perceive
themselves or someone in their families to be susceptible to foodborne illness. Plus,
home kitchens are multipurpose areas and are much more than just food preparation
and storage places.

The role of food handlers, usually mothers, their understanding of the status of
food handling knowledge and practices is needed in ensuring food safety at the
household level is well accepted and currently impossible for food producers to ensure
a pathogen free food supply, thus home food preparers need to take many precautions
to minimize pathogenic contamination because they are the final line of defense
against foodborne illnesses (Fawzi and Shama, 2009).
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However, several studies were conducted to evaluate the food safety


knowledge, attitude and practice (KAP) of food handlers in restaurants and food
establishments. Other target populations for food safety KAP studies were university
students and hospitals staffs or food handlers (Sharif et al, 2013). At the moment, there
is a lack of literature regarding consumer behaviour in the home (Langiano et al,
2012). It is very important to investigate food preparers' knowledge, hygienic practices
and attitudes toward food safety (Ebtisam and Madiha, 2013). Therefore, in line with
main objective, the overall knowledge, attitude and practices (KAP) scores of among
primary food preparers routinely involved with making food for every day meals in
rural area and urban area where it relate with their age, gender and educational level
were explored.

1.3

Objective

1.3.1 General
To evaluate the food safety knowledge, attitude and practice (KAP) of
primary food preparer at home in rural area and urban area.
1.3.2 Specific
1.

To compare the knowledge mean scores between primary food


preparer at rural area and urban area.

2.

To compare the attitude mean scores between primary food


preparer at rural area and urban area.

3.

To compare the practices mean scores between primary food


preparer at rural area and urban area.

4.

To correlate the KAP scores of primary food preparer

1.4

Hypothesis

1.4.1 Hypothesis
1.

There is a significant difference of the knowledge scores


between primary food preparer at rural area and urban area.

2.

There is a significant difference of the attitude scores between


primary food preparer at rural area and urban area.

3.

There is a significant difference of the practices scores between


primary food preparer at rural area and urban area.

4.

There is a significant correlation the KAP scores of primary


food preparer.

CHAPTER 2: LITERATURE REVIEW

2.1

Food safety legislation in Malaysia

The study done by Norazmir et al (2012) stated that from the Ministry of Health
(2006b) the food safety system in Malaysia with different authority entrusted
collaborates together to ensure food safety at different stages of the food chain which
is characterized by its complexity and diversity. Food safety in Malaysia in which is
authorized by the Food Safety and Quality Division. The Ministry of Health Malaysia
under the 1983 Food Act and 1985 Food Regulation that responsible on matters about
food safety and MOH itself have been developed a system on 2003, known as Food
Safety Information System of Malaysia (FOSIM), where it is one of the initiatives
from government in order to increase and improve the information spreading on food
safety to the public particularly. The microbiological guidelines for ready-to eat food
has been approved by the Food Regulation 1985 Technical Advisors Committee on 28
October 2005 as a guideline to enforce microbiological standard for ready-to-eat food
since the Food Hygiene Regulations has not been gazette yet.

2.2

Food safety knowledge

From the study done by Onn Rashdi et al (2009), knowledge is linked with current
practices, in which it turn affects willingness to change current practices if it is learned
that current practices are unsafe. A research by Norazmir et al (2012) reported that the
risk level of foodborne may vary either low or high and every person has a risk of food
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illnesses. Hence, low knowledge on food safety contribute individual to have

high

tendency to contract with any food illnesses. The research also found that recent
studies showed the level of food safety knowledge associated with the socio
demographic and academic variable by increased food safety knowledge with age.
Comparison on food safety knowledge and practices between male and female is
observed and it showed that female have higher practices on food preparation
compared to male but there is no difference in term of knowledge between male and
female. In addition, a research carried out by Annor and Baiden (2011) said that the
educational level did not influence knowledge and practice of food hygiene.
However, the factor that was found to significantly influence knowledge and
practice on food storage and safety, food preparation and food handling and health
problems is the place of work but not their knowledge and practice on hygiene and
cleaning. Besides, Mancini (2013) investigated that the factors most common
contributing to foodborne illness include improper cooking procedures, temperature
abuse, lack of hygiene and sanitation of food handlers, cross-contamination, and
consuming foodsfrom unapproved (non-regulated) sources. Apart from that, according
to Farrish et al (2009), the group people such as young adults, males, and individuals
with higher education generally failed to engage in safe food handling behaviour,
including hand washing and washing cutting boards after working with raw meats.
The study done by Aygen (2012) stated that in all of the food handling, knowledge,
attitudes, and self- reported practices of consumers together with their actual foodhandling behaviours, the consumers were found to be aware of some safe food
handling practices but lacked knowledge of others. So that, it was concluded that
consumer knowledge of food safety was inadequate and required improvement

in

most instances. Moreover, according to Vlasin- Marty (2013), the higher scored in
food safety knowledge is obtained by the individuals who had experience handling
food compared to person who had no experience handling food.

2.2.1 Personal hygiene


Research carried out by Tan et al (2013) found out the personal hygiene covers
the aspect of hand hygiene, clean attire, personal health and personal habit or
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behaviour. The sources in spreading the food-borne diseases can occur directly
because of food handlers with poor personal hygiene, or due to cross
contamination. These factors are influenced largely on the knowledge

and

practices of the food handlers. Hand washing is simplest of all personal


hygiene measures to ensure safe food among handlers.
Odeyemi (2013) conducted a research and it was reported that the most
efficient and effective ways of reducing spread of foodborne pathogens is hand
washing due to its ability to reduce gastrointestinal disease by 12 40 % and
also 20 % of other infections especially when combined with soap. Hence hand
washing constitute the most important factor in food safety among food
producers, handlers and consumers. A study in the Makkah among food service
staff in hospitals showed general positive knowledge toward food safety and
hygiene when it is indicated that the staff knew the using of caps, masks,
protective gloves and satisfactory closing can reduce the risk of food
contamination, meanwhile washing hands before handling food able to reduce
the risk of contamination, and take care of personal hygiene ensures safe food,
and avoids cross contamination (Amany, 2013). In other research by Gadi et al
(2013) reported that poor personal hygiene resulted in higher contamination
(66.6%), can be reduce to (33.4%) where hygiene was fair. This may be due to
dirty clothing, unhygienic handling and serving practices, contaminated hands
and lack of knowledge of hygienic practices.

2.2.2 Cross contamination


Cross contamination is a process of when bacteria from one food item are
transferred to another food item. It could be happen by the way of
unwashed cutting boards or countertops, as well as knives and other kitchen
tools, or even unwashed hands. Cross contamination can lead to food poisoning
and it can be prevent by good food safety habits such as frequent washing of
hands, utensils, cutting boards and work surfaces. In professional kitchens,
different colour cutting boards are used for different foods, such as raw poultry
or fresh vegetables, so that cross contamination is less likely to occur (Alfaro,
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2014). According to Sheen and Hwang (2011), the models for cross
contamination and recontamination of food products are via three routes of
contamination where the routes are equipment, air, and hands. Meanwhile, the
transfer rates for different recontamination scenarios and routes were needed to
properly quantify the risk in a quantitative microbial risk assessment. In
addition, the study done by Mauro et al (2009) showed that the method of food
placing into the fridge is observed where it could be influenced the levels of
contamination. In fact, even against a high level of education, 60.9% of
respondents from their study adopted personal criteria to food placing,
disregarding the risk arising from cross-contamination.
Apart from that, Soares et al (2012) investigated and found out an
important result from this study where almost all respondents that act as food
handlers in schools claimed that they washed their hands before using gloves
and answered correctly that washing hands before work reduces the risk of
food contamination. Then, neither the use of gloves nor even the practice of
hand washing completely eliminated the risk of cross contamination. So those,
the combining the use of gloves with proper hand washing can reduce the risk
of cross contamination. Brown et al (2013) conducted a research and found that
according to the U.S. Food and Drug Administration (FDA) Food Code it is
have a regulatory guidance that aimed at preventing cross-contamination in
restaurants. This guidance includes these prescriptions where it include
properly clean food contact surfaces (includes washing, rinsing, and
sanitizing), minimize bare hand contact with food that is not in ready- to- eat
form like raw chicken and separate raw animal foods from other foods.

2.2.3 Safe temperature of food


Most foodborne pathogens prefer warm environments but can grow in a wide
range of temperatures. There is a temperature danger zone where at this zone
harmful bacteria can multiply and cause foodborne illness. The range of the
temperature danger zone is above 4C (40F) and below 60C (140F). In
Canada, public health experts estimate that 11 to 13 million cases of foodborne
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illness occur each year. Many illnesses are caused by perishable foods like
meat, eggs and dairy products kept too long in the temperature danger zone.
The recommended strategies to avoid foodborne illness are prompt
refrigeration at temperatures at or below 4C (40F) and hot holding food at or
above 60C (140F). According to Mayo Clinic Staff (2011), they said that the
best way to tell if foods are cooked to a safe temperature is to use a food
thermometer. Harmful organisms in most foods can be killed by cooking them
to the right temperature. Ground beef should be cooked to 160 F (71.1 C),
while steaks and roasts should be cooked to at least 145 F (62.8 C). Chicken
and turkey need to be cooked to 165 F (73.9 C). Fish is generally well-cooked
at 145 F (62.8 C).
The study done by Onn Rashdi (2009) stated that pasteurization and
other sterilization processes require stringent assurance that all parts of the
food product have been heated above a certain temperature for a defined period
of time. Then, several studies have reported that main factor contributing to
foodborne outbreaks is poor holding and cooking temperature control. The
growth of certain bacteria through its spores can occurs because of improper
holding and not all of these spores will be destroyed with heating processes.
Thus it is important for all food handlers to recognize their responsibilities in
ensuring that all food prepared were monitored in every stages of its
preparation.

2.2.4 Food from unsafe sources


The first step that can make to ensure food safety is to make sure that the food
arriving at establishment is coming from a safe source. Food that is received
from suppliers that are not practicing food safety can cause a foodborne illness
outbreak. It is advisable do not accept foods from unapproved sources or
which are unsafe, adulterated or out of temperature. A research by Onn Rashdi
(2009) reported that tendency for worry to hazards related to the use of
technology such as hormones, genetic modification applied to food production
is higher. Compare with the hazards related to cost, diet, hygiene and other
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lifestyle issues, the worrisome of use of technology is more troublesome to


them.

2.3

Food safety attitudes

A study done by Saidatul and Hayati (2013) defined an attitude as a measure of degree
to which a person has favourable or unfavourable evaluation towards behaviour. For
every person who involved in food service operation, food safety become one of the
responsibility to handle food and general food handling mistakes besides

serving

contaminated raw food also includes inadequate cooking, heating, or reheating of food
consumption of food from unsafe sources, cooling food inappropriately and allowing
too much of a time lapse. Those errors might lead to food poisoning.

Campbell

(2011) explained that attitude involves evaluative concepts associated with the way
people think, feel and behave. Besides, attitudes may influence someone intention to
perform a given behaviour or practice. Thus, it correlated with behaviour, for instance
if a person has a positive attitude towards appropriate hand washing, they are more
likely to wash their hands.
Research carried out by Amany (2013) found out positive attitude was
observed more in employees who worked in hospitals that had not adopted the
HACCP standard and this is can be conclude that informal sources such as lack of
specific training, empirical adoption of safe attitudes and behaviours based on skill in
the working and domestic setting become the factor to achieve this positive attitude.
Mizanur et al (2012) explained that the superficial knowledge leads to misconception
and development of negative attitudes. As a result, it contributes to increases of
harmful practice. In fact, many vendors have sufficient knowledge to ensure hygienic
handling of food, such as the knowledge of the dangers of contamination,

storage,

preparation of food. Then, Nee and Norrakiah (2011) conducted a research reported
that about 56.9% and 66.2% of respondents respectively, stated that there are a ways
to cause harmful to health like not monitoring refrigerator and freezer temperatures
and improper storage of foods.

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2.3.1 Inadequate cooking


Based on Food Poison Journal, although practices of food suppliers and food
service establishments are important in reducing foodborne illness, research
has shown that a substantial proportion is associated with improper food
handling, preparation and consumption practices in the home. These can
include

inadequate

cooking,

inadequate

cooling

and

storage,

cross

contamination of raw and cooked foods, consumption of raw, undercooked or


unsafe foods, and inadequate personal hygiene. Proper cooking is one of the
best means of making sure the operation does not cause a food-poisoning
outbreak. Proper cooking will function in kills all pathogens (except spores) or
at least reduces their numbers to a point where they cannot make people sick.
There is an accident that will make inadequate cooking occur like cooking still
frozen poultry or meat or using an inexperienced cook. According to Langiano
et al (2012), the study found that adequate cooking is effective towards killing
such pathogens when some individuals consumed raw foods which facilitate
the toxic abilities of foodborne pathogens.

2.3.2 Reheating of food


Reheated of food too slowly can cause the bacteria grow in food. If the food
reheat previously cooked and cooled potentially hazardous, the food must
reheat it rapidly to 60C or hotter. To reheat food to 60C, at least within a
maximum of two hours to minimise the amount of time that food is at
temperatures that favour the growth of bacteria or formation of toxins.
According food protection service (2009), the foods that cooked or reheated in
a microwave oven, they must be cooked or reheated in a covered container;
rotated or stirred at least once during the cooking or reheating and allowed to
stand covered for 2 minutes after cooking before serving. To check the internal
temperature of the food, food thermometer must be use always. There are a
ways to reheat leftover thoroughly by cover leftovers to reheat that function to
retains the moisture and ensures that food will heat all the way through. Then,
thaw frozen leftovers safely in the refrigerator or the microwave oven. When
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thawing leftovers in a microwave, continue to heat it until it reaches 165 F as


measured with a food thermometer. A research conducted by Fawzi and
Sharma (2009) reported about half of them recognized raw or half cooked food
of animal origin, and inadequately reheated cooked food as causes of food
poisoning (54.4 and 53.3% respectively).

2.3.3 Cooling food inappropriately


According to Department of Health New York (2005) the potentially
hazardous foods that require refrigeration must be cooled by an adequate
method so that every part of the product is reduced from 120 degrees
Fahrenheit to 70 degrees Fahrenheit within two hours, and from 70 degrees
Fahrenheit to 45 degrees Fahrenheit or below within four additional hours.
Food poisoning bacteria that may have survived the cooking process will start
to multiply as hot food cools down. Some pathogens can form heat resistant
spores where it can survive at cooking temperatures. When the food begins
cooling down, and enters the danger zone, the spores begin growing and
multiplying. If the food spends too much time in the danger zone, the
pathogens will increase in number to a point where the food will make people
sick. There are some ways to cool food rapidly by place food to cool in
refrigerator or cool- room as soon as it stops steaming. Then, ensure cool air
can circulate round the food. Besides, place liquid foods such as stews in
shallow containers no more than 5 cm deep. The research by Langiano et al
(2012) found out that 24.0% of cooked foods were stored in the refrigerator
after cooling to room temperature, while 28.0% were stored in the refrigerator
within 24 hours if not consumed and it showed that the respondents know how
to handle food at home.

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2.4

Food safety practices

Fawzi and Shama (2009) conducted a research and reported that from food preparation
practices at home cause the percentage of food poisoning cases arising under
represented in outbreak statistics. The research also found that the results show the
mean score percentages of food safety practices in two food safety parameters;
preparation and cooking (69.0 and 77.5; respectively) were higher than their
corresponding knowledge (59.8 and 70.0). This indicates that some women have
deficient of knowledge but used to do the right practices. This can be describe as
women may be taught the right preparation and cooking practices from their mothers
or other relatives without having the correct knowledge. Then, Mizanur et al (2012)
investigated that food vendors practice of food safety revealed that it was 4.039 times
higher with good practice and 2.834 times higher with average practice of food safety
among respondents with history of food safety training. In other study that conducted
by Sharif et al (2013) in the military hospitals showed that the correct practices for
hand hygiene do not necessarily in extensive knowledge that result in the appliance of
these methods because of the work place barriers. These barriers come from the work
staff, including inhibitory attitudes of supervisors and colleagues, time pressures
and/or lack of staff, as well as structural factors, such as facilities and accessibility to
supplies. In conclusion, multidimensional training of food handlers should be carried
out in approach that covering social, environmental and organizational factors, and
with greater focus on risk perception that may lead to unsafe practices.
According to Norazmir et al (2012), the study reported the female and
respondents who were better-educated and who used newspapers/magazines or
televisions were all more likely to report willingness to change their cooking practices.
Moreover, a research conducted by Kasturwar and Shafee (2011) reported regarding
practices of food handlers, 79(95.2%) study subjects, before food preparation and
serving they washed their hands with soap and water, only 4(4.8%) male did not
practice it although all the study subjects knew that hands should be washed with soap
and water before food preparation and serving. However, only the minority about
27(32.5%) were knew that food can lead to diarrhoea, vomiting and abdominal pain
and a negative knowledge the majority of study subjects 56(67.5%) about the diseases
transmitted through food. According to Langiano et al (2012), the research observed
15

numerous factors related to the onset of foodborne illnesses due to inappropriate food
safety practices where it is important that correct food handling and storage procedures
are essential measures for assuring food safety in the home.
Byrd- bredbenner et al (2013) carried out a research and found out the
consumers recognize they are responsible for food safety is about 6 in 10 customers
and nearly all say they gave at least some thought to food safety. However, there are
gaps in consumer applications of Clean, Separate and Chill advice from the Dietary
Guidelines for Americans and food safety programs like Fight Bac! and the World
Health Organizations Five Keys to Safer Food, that have been documented in the
U.S., Australia, Ireland, Italy, Slovenia, and Turkey. In addition, inconsistent practices
among home food handlers can negate much of the effort made in improving and
maintaining food safety achieved earlier in the food chain.
2.4.1 Clean
A study done by Byrd- bredbenner et al (2013) explained that the purpose of
clean is to prevent the transfer of disease or cross contamination that causing
microorganisms travel from one food, object, or surface to another food by
washing hands, food contact surfaces, and kitchen equipment. Norazmir et al
(2012) conducted a research in a school and reported that the respondents
always washed their hand before eating or preparing food at home
approximately about 80.7% of female respondents and 64.4% of male
respondents. Besides, they also express that they wash their hand before eating
food in the school canteen or restaurant with close percentages, 67.3% for male
and 65.0% for female. Thus, it showed the majority of respondent have high
level of practices and cleanliness on food safety. A research conducted by
Alrabadi et al (2013) reported that the general hygiene rules of preparing food
are cared by them where 41% of the respondents always check the cleanliness
of the surfaces where they prepare food and 37% do so frequently.
Additionally, nearly all of them always or frequently washed their hand before
preparing any food. Besides, a chopping board or knife that have been used to
prepare raw meat must never be used when to prepared ready-to- eat foods
unless they have been washed thoroughly first (Annor and Baiden, 2011).
16

Research carried out by Langiano et al (2012) explained it was not


necessary to clean and disinfect cutting boards between preparing different
foods among their respondents. In fact they reported that between uses of the
same cutting board when prepare of raw and cooked food, they do not
cleansing the cutting board with soap. In addition, they were more likely to use
wooden cutting boards that likely more increasing the potential risk of crosscontamination. Apart from that, a large number did not believe it was necessary
to wash their hands after handling raw meat, poultry or fish. These behaviours
are associated with pathogens like Salmonella sp. The study by Fawzi and
Shama (2009) stated only 4.4% from their respondents that works as clerks
were usually clean the salad vegetables by soaking them in water with
potassium permanganate at their home.

2.4.2 Separate
According to Byrd- Bredbenner (2013) study, the goal of separate is to keep
raw meat, poultry, and seafood separate from ready-to-eat foods. The study
done by Langiano et al (2012) reported the potential risk for foodborne
diseases from their study was cross contamination of refrigerated food storage.
Behaviours need to be related to keeping foods at a proper distance in order to
prevent illnesses caused by Bacillus cereus and Clostridium perfringens and
Staphylococcu aureus. The research also found that food was generally stored
in sealed containers in the refrigerator only 40.9%, meanwhile in free spaces
39.4% and direct contact between cooked and raw foods was only avoided in
36.5%. Thus, this indicates the unawareness of the risk of cross contamination.
Then, research carried out by Amany (2013) found out a positive attitude was
reported by most of the food service staff, 92.5% agreed that raw foods should
be kept separately from cooked foods. Aygen (2012) reported in a research,
most of the respondents (89%) seem to know that the same plate cannot be
used for both raw and cooked meat before being washed

17

2.4.3 Chill
A research by Byrd- Bredbenner (2013) described chill focuses on the
refrigerators critical role in temperature control. However, it is important to
also think about clean and separate in this appliance. Studies indicate that
refrigerators in many households are not clean. The study done by Annor and
Baiden (2011) showed that respondents from their study used a methods of
defrosting meat or poultry, where males chose to thaw in cooling units rather
than risk thawing at room temperature. Compared to females (61.9%) that
prefer to leave the meat or poultry at room temperature, the majority of the
males (85.7%) chose to defrost - meat or poultry in a refrigerator/ cold room, in
the defrost cycle in a microwave, or in a basin of cold water. Food must never
be defrosted at room temperature and it is essential to keep meat and poultry
cold and defrosting is required to prevent the growth of harmful bacteria. There
is greater danger of bacterial growth and food spoilage for food thawed at room
temperature. Thus, the best way to safely thaw meat and poultry is in the
refrigerator.
A research done by Nee and Norrakiah (2011) reported that about
56.9% and 66.2% of respondents respectively, stated that not monitoring
refrigerator and freezer temperatures and improper storage of foods that might
be harmful to health. Amany (2013) conducted a research and explained that
81.0% of the respondents were unaware of the correct working temperature of
a refrigerator; 22.0% did not know that refrigerators and freezers should be
controlled periodically (79.0% and 87.5%) respectively and did not know the
proper storage temperature of hot and cold ready to eat foods. According to
Aygen (2012), the research reported that based on the majority of respondents
(about 88%) have thought about this to be very/quite important, only 50.6%
stated that their refrigerator had a thermometer indicating the internal
temperature of the fridge while 35.5% stated that it did not have such a
thermometer. Meanwhile, 13.9% indicated that they had not looked to see if
there was such a thermometer in/on their refrigerators. However, of those who
indicated that there was a thermometer, 45.5% knew the correct temperature at
which a refrigerator should operate up to 5C
18

CHAPTER 3: METHODOLOGY

3.1

Study design

3.1.1 Cross sectional study


This is a cross- sectional study that was been conducted in rural areas within of
Hulu Dungun, Terengganu and urban area of Kajang, Selangor where it has
been selected randomly with a view to assess the level of knowledge, attitude
and food safety practices among the primary food preparer at home. The
survey was conducted from September 2014 to December 2014.
3.2

Target population and sample size


The primary food preparer at home either mother or father that act as the food
handlers in rural area of Hulu Dungun and urban area of Kajang has become
the target population for this study. A total of 100 houses from each area have
been involved in this survey. The respondents who is agreed to enrol in this
study protocol, a survey already conducted using questionnaire based interview
at the private home of each respondents.

3.3

Materials and methods


3.3.1 The questionnaire
The questionnaire has been divided into three sections. All the third sections
are regarding about the KAP. For the KAP survey, a modified questionnaire by
Sharif and Al-Malki (2010) has been used for knowledge, attitude and practices
of the food handlers. The questionnaire is classified into food safety knowledge
19

section, food safety practices and food safety attitude. For the knowledge
section consists of 15 questions, attitude section involve 15 questions and
practices section has 20 questions. All questions about knowledge has been
asked to choose from among three options- yes, no or dont know to reduce the
response bias. Meanwhile, the attitudes questions have been a score on a fivepoint scale (0 to 4) with options of strongly agrees, agree, not sure, disagree or
strongly disagree. However, the questions about practice have been a score on
a five-point scale (0 to 4) with options of always, most of the times, sometimes,
rarely or never. For dichotomous classification the scores less than 2 were
categorized as a positive response, (Answering right) while the scores 2, 3 and
4 were categorized as a negative response (Answering wrong). All answers to
questions are written down manually by the interviewer and the time used to
complete an interview is approximately in 45 minutes.
3.3.2 Pre test
The reliability of the food safety questionnaire is determined by pre- study on
30 food handlers. These respondents were not included in the final survey. The
reliability coefficient test is 0.50 and as the result of the item analysis, several
questionnaires were modified to improve clarity.
3.3.3 Data analysis
The data entry was started immediately after completion of data collection. The
collected data was checked, verified and entered into the computer. The
analysis was been carried out with SPSS (Statistical Package for Social
Science) version 19. The mean scores for knowledge, attitude and practices
was been analyzed using independent t- test and one way ANOVA. For the
correlation KAP score of primary food preparer, bivariate correlations was
used.

20

CHAPTER 4: RESULT

4.1

Descriptive Analysis

4.1.1 Level Knowledge Mean Score between Urban and Rural Area

According to the KAP questionnaire, the knowledge section is divided into


four parts. The parts are personal hygiene, cross contamination, safe temperature of
food and food from unsafe sources. According to the result from the table 1.1, the
means for questions 4 and 14 are the lowest for the both area because all of the
respondents which is the primary food handlers are showed 100% understanding about
personal hygiene after going to the toilet and the cleanliness of the place when
purchasing of food. The results also stated that, most of the questions showed the
significant differences (p< 0.05) level of knowledge about food safety among primary
food handlers at home for both areas. From six questions about personal hygiene, out
of four are showed significant difference. Meanwhile for the cross contamination,
from five questions only one showed no significance difference. All four questions
about safe temperature of food and food from unsafe sources showed that there is no
significant difference regarding about that and it can be conclude that the rural area
and urban area have same level in term of safe temperature of food and food from
unsafe sources.

21

Table 1.1: Knowledge Mean Score between Both Areas.

Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
Question 7
Question 8
Question 9
Question 10
Question 11
Question 12
Question 13
Question 14
Question 15

Urban area
(mean s.d)

Rural area
(mean s.d)

P value between group

1.02 0.14
1.02 0.14
1.09 0.29
1.00 0.00a
1.04 0.20
1.29 0.45
1.06 0.24
1.11 0.31
1.14 0.35
1.07 0.26
1.12 0.33
1.19 0.40
1.20 0.40
1.00 0.00a
1.45 0.50

1.16 0.37
1.12 0.33
1.13 0.34
1.00 0.00a
1.24 0.43
1.10 0.30
1.09 0.29
1.24 0.43
1.35 0.48
1.11 0.31
1.03 0.17
1.21 0.41
1.21 0.41
1.00 0.00a
1.50 0.50

0.001*
0.005*
0.369
0.001*
0.001*
0.423
0.015*
0.001*
0.325
0.016*
0.725
0.862
0.481

* Significant p < 0.05

4.1.2 Level Attitude Mean Score between Urban and Rural Area
Based on the KAP questionnaire, the attitude section cover of three categories
where the categories are inadequate cooking, reheating of food and cooling food
inappropriately. The results showed that mostly of the questions have significant
differences between urban area and rural area. For the inadequate cooking, the
question about well- cooked foods are free of contamination, both area respondents are
well attitude and answer correctly. Because of that, the result showed there is no
significant difference on question 1. For the questions that p value is 0.001, there is a
huge difference in answering the questions between these two areas where the primary
food preparer at urban more attitudes compared to the rural area. As example, question
2 asking about the usage of thermometer when prepared the food, and as the result
collected, the finding showed that urban area more prefer using the thermometer.

22

Table 2.1: Attitude Mean Score between Both Areas

Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
Question 7
Question 8
Question 9
Question 10
Question 11
Question 12
Question 13
Question 14
Question 15

Urban area
(mean s.d)

Rural area
(mean s.d)

P value between group

1.02 0.014
1.05 0.219
1.13 0.338
1.25 0.435
1.07 0.256
1.03 0.171
1.00 0.000
1.09 0.288
1.25 0.435
1.39 0.490
1.06 0.239
1.02 0.141
1.00 0.000
1.08 0.027
1.14 0.349

1.00 0.000
1.45 0.500
1.52 0.502
1.11 0.314
1.60 0.492
1.29 0.456
1.22 0.416
1.44 0.499
1.57 0.498
1.41 0.494
1.10 0.030
1.05 0.219
1.19 0.394
1.13 0.338
1.20 0.402

0.157
0.001*
0.001*
0.010*
0.001*
0.001*
0.001*
0.001*
0.001*
0.774
0.300
0.251
0.001*
0.251
0.261

* Significant p < 0.05

4.1.2 Level Practices Mean Score between Urban and Rural Area
In the practices questionnaires, it consists of three categories which are clean,
separate and chill. In these questions, there are two questions that used the reverse
directions of the scale in order to check the validity of responses. Based on the result,
for the clean section, question two, four and five showed no significant difference.
This is means that, between rural and urban their attitudes regarding cleanliness are
equal. However, from seven questions in clean section there are four questions that
showed the significance. It can be concluded that, only the certain part of clean section
their attitude are equal but overall, the urban area attitude is more better than rural area
based on their score when answering the questions. In the separate section, out of four
from six questions, it showed that there is no significant difference between both
areas. Thus, it can be said that, the level attitude about separate between rural area and
urban area are same. In this section also, question 12 does not stated any value for the
p< 0.05 because of all attitude of respondents regarding placing the raw food and
cooked food in same plate showed that they all have 100% attitude about that. Lastly,
for the chill section, only the question 16 does not show the significant difference
23

where between rural area and urban area, the respondents have good attitude when
involve with re-freeze the food after thawed. Most of the questions in chill section are
about how the respondents take care of their food after put in the refrigerator.
Table 3.1: Practices Mean Score between both Areas

Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
Question 7
Question 8
Question 9
Question 10
Question 11
Question 12
Question 13
Question 14
Question 15
Question 16
Question 17
Question 18
Question 19
Question 20

Urban area
(mean s.d)

Rural area
(mean s.d)

P value between group

1.00 0.000
1.15 0.359
1.19 0.394
1.05 0.219
1.02 0.141
1.08 0.273
1.05 0.219
1.29 0.456
1.31 0.465
1.45 0.500
1.28 0.451
1.00 0.000a
1.28 0.451
1.16 0.368
1.35 0.479
1.14 0.349
1.25 0.435
1.47 0.501
1.13 0.338
1.35 0.482

1.04 0.197
1.19 0.394
1.03 0.171
1.10 0.301
1.08 0.273
1.22 0.416
1.19 0.394
1.32 0.469
1.41 0.494
1.57 0.498
1.48 0.502
1.00 0.000a
1.49 0.502
1.31 0.465
1.61 0.490
1.07 0.256
1.04 0.196
1.13 0.338
1.25 0.435
1.61 0.490

0.044*
0.454
0.001*
0.181
0.052
0.005*
0.002*
0.647
0.142
0.090*
0.003*
0.002*
0.012*
0.001*
0.107
0.001*
0.001*
0.031*
0.001*

* Significant p < 0.05


4.1.3 The Correlation of KAP Scores of Primary Food Preparer.
Table 4 and 5 shows the correlation of KAP scores of primary food preparer.
Table 4 represent the correlation between knowledge and attitude where the results is
showed that there is a significant difference between these two things at p< 0.01. This
means that, all respondents have high knowledge and good attitude towards their food
safety. Meanwhile for the table 5, it represents the correlation between attitude and
practices of primary food handlers. The results showed there is a significant difference
at level p< 0.01. thus, it can be said that a good attitude produces a high practices
among them.

24

Table 4.1: The Correlation between Knowledge and Attitude

knowledge
attitude

Knowledge

Attitude

Correlation coefficient

1.000

1.000*

Sig. (2 tailed)

Correlation coefficient

1.000*

1.000

Sig. (2 tailed)

* Correlation is significant at 0.01 levels (2- tailed)

Table 5.1: The Correlation between Attitude and Practices


.
Attitude
practices

Attitude

Practices

Correlation coefficient

1.000

1.000*

Sig. (2 tailed)

Correlation coefficient

1.000*

1.000

Sig. (2 tailed)

* Correlation is significant at 0.01 levels (2- tailed)

25

CHAPTER 5: DISCUSSION

This investigation provides valuable information about the level, attitudes and
practices in food safety among the primary food preparer at home in rural and urban
area. An important result from this study about level knowledge of primary food
preparer was that 100% of respondents were known that after using toilet they need to
wash their hand and also the cleanliness of place their purchasing the food. Most of
them also answered correctly that washing hands before works can reduces the risk of
food contamination and licking the fingers can increase the risk contamination.
However, based on the question when having injured at finger, the rural area showed
unsatisfactory knowledge where they do not know they need to wear gloves and most
of them just prefer to wrap their finger with clean cloth. The result is differently from
previous study where most of the food handlers agreed with the statements when
having cuts on hand they should avoid from unwrapping the foods and need to wear
gloves if they intended to do so (Nee & Norrakiah, 2011). In contrast with that, the
urban primary food handlers show middle level of knowledge about taking bath and
wear clean cloth before handling with food where most of them did not take a bath and
it is more differ from the previous study where according to Kasturwar and Shafee
(2011), their study showed that all respondents taking bath and wearing clean cloth.
Besides, the other questions about personal hygiene, the respondents also able to
answered correctly. A study of food handlers at residential colleges and canteen
regarding food safety showed that respondents have good knowledge on personal
hygiene where 93.9% answered correctly (Nee and Norrakiah, 2011).
For the cross contamination, the both area able to answer correctly but there is
a huge difference on the question about the raw vegetables is more risky than less
cooked beef. The significant difference is p< 0.016 and the most the urban primary
food preparer answered wrongly because they thought that the raw vegetables is more
26

healthier such as salad. For the rural, they answered rightly because they produced
their own vegetables and knew that what kind of pesticides they used. For the
questions about food from unsafe sources, respondents from both areas are selective in
finding clean shop when purchasing the food. These findings are compatible with
previous study by Alrabadi et al, (2013) where the Jordanian consumers seemed to
follow safety rules when they purchasing their food products. In general, only the few
questions that both areas have same knowledge and rest of the questions, it showed
some significant difference.
In attitude questions, the selection of answer was given five options and when
analyzed the data, it was divided into two groups which are positive answers and
negative answers. For the primary food preparer attitudes for both areas, the result
showed a significant difference for the most questions. In this questions, there are
some question that a rural area respondents where have good attitude and it also same
goes with an urban area respondents. In this present study, respondents from rural area
showed a low attitude about the usage of thermometer when prepared the food
meanwhile urban area respondents showed a good attitude. In previous study also
stated that 72% of the respondents never use a thermometer in a food preparation
(Alrabadi et al, 2013). So, it can be said that although the usage of thermometer is
important but rarely of food handlers used it. When the question involve with the half
cooked food, the rural area respondents showed the positive attitude where they not
preferred to cook half food compared to the urban area.
For the question regarding of reheating of food, the result showed the
significant difference where the primary food preparer not so good attitude. They more
preferred to answer not sure and it was categorized under the negative answer. Only
one question about the food that potentially to contaminate need to be reheated almost
2 hours get the correct answered and both of the areas respondents answered
positively. The attitude for cooling the food showed that there is no significant
difference between these two areas. Only one questions showed the significant where
the question asking about the cooked chicken or beef that be leaved at room
temperature will cause the contamination and respondents from rural mostly answered
not sure. It differ from the urban respondents where they agreed with this statement

27

and doing that attitude. The previous study by Sharif et al, 2013 also showed the
positive answer about storing cooked food for less than 4 hour at room temperature.
The questions for the practices were divided into three where it more focuses
on clean, separate and chill. There are also two questions that used reverse scale
scoring in order to get the validity. Most of the questions have significant difference
between rural area and urban area. One of the questions that have been asking is about
the cleanliness of vegetables where the rural wash it properly compared to the urban.
Then, the difference answers between rural area and urban area can be seen at their
practices either they are washing the eggs or not before used it and the urban
respondents showed the positive answers where they know that at the shell of eggs
contain bacteria Salmonella sp. For the separate section, the average for the rural
primary food preparer and urban food preparer are equal where they all knew that the
cooked food must be separate from the raw food. However, both areas respondent
have bad practices when they mix the cleaning products with the closed food such as
biscuits. For the chill section, the question asking about the temperature of refrigerator
where rural area showed negative answer compared to urban area and it showed the
contrast from the previous study by Nee and Norrakiah (2011) where their respondents
were correctly answered about time and temperature control. Then, the rural also
showed negative answer and practices where most of them thawed the chicken in a
bowl and they leave it at room temperature. However, from the previous study by
Alrabadi et al (2013), their respondent also have a lack knowledge about the proper
method of thawing frozen food, where 90% thought the correct way is to keep them
overnight at room temperature.
For the correlation of KAP score, knowledge and attitude showed the
significant relationship where it showed that a higher knowledge contribute to the
good attitude whereas the correlation of attitude and practices also showed the
significant relationship in which a good attitude give a positive feedback towards a
better practices.

28

CHAPTER 6: CONCLUSION

As the conclusion for this study, the hypothesis for the significant difference of
knowledge of primary food preparer between rural area and urban area is accepted.
Meanwhile the hypothesis for the significant difference of attitude also is accepted.
Lastly, the hypothesis for the significant difference of practices also is accepted. Thus,
this investigation provides valuable information about the knowledge; attitude and
practices in food safety of primary food handlers at home in rural area and urban area.
At this moment, it is unlikely that domestic food handling will reach the same level as
food safety control in food industry preparation. However, overall safety procedures of
food handling, storage and preparations need to be indicated to consumers. The
established food safety management system (e.g. HACCP, GHP, GMP) ensures food
safety throughout the entire food chain from farm to table, but needs to adapt
additional measures in order to guarantee correct hygiene and food safety in the home.

6.1

Limitations
There are a few limitations in this study. Firstly, there are too difficult to find

the male primary food preparer at home in the rural area. Means that, if more men
involved in this survey, the results maybe showed some difference where in certain
question they maybe have different opinion from women. Next is, mostly the
participants from the urban did not cook at their home and more prefer to eat ready-toeat food. Thus, a little bit it influences their answers in this survey.

29

6.2

Recommendations for future research


Health Education intervention can be developed in order to have improvement

in knowledge, attitude and practices towards food- borne disease and food safety
especially in rural area. Although it is recognized the need for further study to assess
the food safety knowledge, knowledge, and attitude among consumers using more
comprehensive assessment tools and more representative samples, the results from this
study indicate that there is a need for food safety education in this target group.
Markets, health centers, and mosques would be an effective place to reach the
consumers with food safety education, which should attempt to affect the consumers
perceived susceptibility to food borne illness.

30

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