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Accepted Manuscript

Knowledge, attitudes and practices of food handlers in food


safety: An integrative review

Laís Mariano Zanin, Diogo Thimoteo da Cunha, Veridiana Vera


de Rosso, Vanessa Dias Capriles, Elke Stedefeldt

PII: S0963-9969(17)30345-9
DOI: doi: 10.1016/j.foodres.2017.07.042
Reference: FRIN 6839
To appear in: Food Research International
Received date: 13 April 2017
Revised date: 7 July 2017
Accepted date: 13 July 2017

Please cite this article as: Laís Mariano Zanin, Diogo Thimoteo da Cunha, Veridiana Vera
de Rosso, Vanessa Dias Capriles, Elke Stedefeldt , Knowledge, attitudes and practices of
food handlers in food safety: An integrative review, Food Research International (2017),
doi: 10.1016/j.foodres.2017.07.042

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Knowledge, attitudes and practices of food handlers in food safety: an


integrative review

Laís Mariano Zanina, Diogo Thimoteo da Cunhab, Veridiana Vera de Rossoc,


Vanessa Dias Caprilesd, Elke Stedefeldte*.

a
GeQual—Study Group of Food Quality. Programa de Pós-Graduação em
Nutrição, Universidade Federal de São Paulo. Botucatu St., 862 – ZipCode:

PT
04023-062, São Paulo – SP, Brazil. zanin.lais@gmail.com
b
GeQual—Study Group of Food Quality. Faculdade de Ciências Aplicadas,

RI
Universidade Estadual de Campinas. Pedro Zaccaria St., 1300 - ZipCode:

SC
13484-350, Limeira - SP, Brazil. diogo.cunha@fca.unicamp.br
c
GeQual—Study Group of Food Quality. Departamento de Biociências,
NU
Universidade Federal de São Paulo, Campus Baixada Santista. Silva Jardim
St., 136 – ZipCode: 11015-020, Santos – SP, Brazil. veriderosso@yahoo.com
d
GeQual—Study Group of Food Quality. Departamento de Biociências,
MA

Universidade Federal de São Paulo, Campus Baixada Santista. Silva Jardim


St., 136 – ZipCode: 11015-020, Santos – SP, Brazil. vancapri@gmail.com
e
GeQual—Study Group of Food Quality. Centro de Desenvolvimento do Ensino
D

Superior em Saúde, Universidade Federal de São Paulo. Pedro de Toledo St.,


E

859 – ZipCode: 04039-032, São Paulo – SP, Brazil. elkesnutri@gmail.com


PT

*Corresponding author
CE

Centro de Desenvolvimento do Ensino Superior em Saúde, Universidade


Federal de São Paulo.
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Postal Adress: Pedro de Toledo St., 859 – ZipCode: 04039-032, São Paulo –
SP, Brazil
e-mail: elkesnutri@gmail.com | +55 (11) 98201.6468

Abstract
This study presents an overview of the relationship between knowledge,
attitudes and practices (KAP) of food handlers with training in food safety, in
addition to proposing reflections on the training of food handlers, considering its
responsibility for food safety and health of consumers. The review was based
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on the integrative method. The descriptors used were: (food handler),


(knowledge, attitudes and practice) and (training). Six databases were
searched, 253 articles were consulted and 36 original articles were included.
Fifty per cent of the articles pointed that there was no proper translation of
knowledge into attitudes / practices or attitudes into practices after training..
Knowledge, attitudes and practices of food handlers are important for identifying
how efficient training in food safety is allowing prioritize actions in planning

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training. The evaluation of KAP is the first step to understand the food handler´s
point of view. After this evaluation other diagnostic strategies become

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necessary to enhance this understanding.
Keywords: Foodborne disease; Food handlers; Training; Food safety;

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Diagnostic strategies. NU
1 Introduction
MA

According to the WHO (2015), every year approximately 600 million


people become ill after consuming contaminated food. Among these victims, an
estimated 420,000 die, including 125,000 children under the age of 5 years.
D

However, cases of Foodborne Diseases (FBD) often are underreported,


E

generally due to non-identification of symptoms or no symptoms compared with


PT

pathogenic microorganisms (Scallan & Ângulo, 2007) or due some diseases


have temporary symptoms, so people do not seek health care (MacDougall et
CE

al., 2008). Food safety is a critical component of sustainable development, and


problems that occur in one country may put others at risk, because the food
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globalization process has shown a significant impact on the food safety (Scott,
2003). This globalization process has focused on production, distribution, and
marketing on a large scale and seeks to meet the needs of the expanding
global population. An asymmetry of information in the globalization of food,
however, can lead to market failures characterized by the presence of
biological, chemical and physical hazards. To make credible and sustainable
legal and policy decisions, the decision-making process must be based on
strong evidence. Considering the growing complexity of the food safety field,
innovative approaches are required to improve prioritization, accounting for the
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overall available knowledge and the need to integrate new scientific


developments quickly (WHO, 2013).
Inappropriate handling practices can cause food contamination and FBD
consequently, impairing the health of the consumer (Howes, McEwan, Griffiths,
& Harris, 1996; Greig, Todd, Bartleson, & Michaels, 2007).
Thus, a generally used tool to ensure the hygienic-sanitary quality is the
application of the model Knowledge, Attitudes and Practices (KAP) (Bas, Ersun,

PT
& Kivanç, 2006; Ko, 2013; Da Cunha, Stedefeldt & De Rosso, 2014a). The
premise of the KAP model is that the food handler, provided with knowledge,

RI
are able to improve their food safety practices voluntarily. So, training, the most
widely used strategy to improve food safety (Medeiros, Cavalli, Salay &

SC
Proença, 2011), may be effective. On the other hand, some authors disagree,
arguing that training, and thus knowledge alone, are not sufficient to improve
NU
practices (Rennie, 1994; Park, Kwak & Chang, 2010; Da Cunha et al., 2014a).
Current evidence for the effectiveness of food hygiene training is
MA

limited/scarce. Review studies can help to make relationship between training


and food safety KAP clearer, these relationship can be used to establish
effective food safety strategies diagnosis and can foster the revision of laws
D

regarding food handling.


E

In the last decade, several studies were conducted in order to assess


PT

KAP of food handlers in different sectors so as to understand their behaviors


and relate them to the causes of FBD (Angelillo, Viggiani, Rizzo & Bianco,
CE

2000; Bas et al., 2006; Ansari-Lari, Soodbakhsh & Lakzadeh, 2010; Soares,
Almeida, Cerqueira, Carvalho & Nunes, 2012; McIntyre, Vallaster, Wilcott,
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Henderson & Kosatsky, 2013).


This study presents an overview of the relationship of food safety
knowledge, attitudes and practices of food handlers with training in food safety.
Based on this information, it offers reflections on the training of food handlers,
considering its responsibility for food safety and the consumer health.

2 Methodology
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The conduct of the review and the process of identification, selection and
classification of articles were based on the method of integrative literature
review. This method comprises the review, criticism and synthesis of
representative topics of literature aiming a new structure and perspective of the
subject studied (Torraco, 2005).
The search of the articles was conducted in the bases of ScienceDirect,
Medline and Lilacs databases, and the Web of Knowledge platform that

PT
includes the foundations of Web of Science, Derwent Innovations Index and
Scielo Citation Index database. The search was limited to full text articles

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written in English, Portuguese and Spanish (domain language of the authors),
published since 2000. It was used the following descriptors, using the Boolean

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terms: (food handler), (knowledge, attitudes and practices) and (training).
Only studies that addressed the triad “knowledge, attitudes and practices” of
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food handlers regarding food safety were included in this review. Were included
either studies that authors assessed a training strategy or compared trained
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food handlers from untrained ones. The studies that addressed only
"knowledge" or "attitudes" or "practice", or a combination of two these terms
were included only to account the number of articles published in the area and
D

not for the integrative review. The criteria for exclusion of the articles were: not
E

specifically KAP approach in food safety, not KAP approach to food handlers,
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only approach of knowledge or attitudes or practices.


After the search, the articles were selected for the title, abstract and final
CE

step to include was the reading of the articles in full. Were consulted 253
articles and 36 original articles were selected fulfilling the inclusion and
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exclusion criteria. Last search was carried out on February 2017..

3 Results and discussion

3.1 Knowledge, attitudes and practices in food safety: emerging themes


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Of the 36 included studies, 8 (22.2%) were conducted in Malaysia, 5


(13.9%) in Brazil, 3 (8.3%) in Vietnam, 2 (5.5%) in Iran, 2 (5. 5%) in Italy, 2 (5.
5%) in Turkey, 2 (5.5%) in India and 1 (2.8%) on each of those countries: USA,
Haiti, China, Canada, Taiwan, Egypt, Spain, Thailand, Saudi Arabia,
Netherlands, Ghana and Lebanon. Majority of KAP surveys were conducted in
developing countries.
Food safety behavior is an important aspect for food business

PT
management and public policy stakeholders, regardless of the country's
economic status, since most foodborne outbreaks occurs due inadequate food

RI
handling (FDA, 2009; Todd, Greig, Bartleson & Michaels, 2007). Notably, there
is increasing government involvement in controlling and regulating the sector to

SC
ensure food quality and reduce FBD. The different level of government
involvement in food safety regulation reflects the practices developed locally
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and consequently the studies conducted in those countries (Martinez, Fearne,
Caswell & Henson, 2007). There is no precise explanation on why most studies
MA

on food safety KAP studies were conducted primarily in developing countries.


Possibly, in countries where food safety regulation is more mature (i.e. Canada,
USA, countries from European Union), many of them with mandatory
D

application of the HACCP system, the interest is greater in the application of


E

management systems than food handlers’ behavior. Figure 1 shows the number
PT

of articles published each year and separated in articles that addressed only
“knowledge” or “attitudes” or “practice” or a combination of two these terms and
CE

articles that addressed the triad “knowledge, attitudes and practices” of food
handlers regarding food safety that are included in the inclusion criteria of this
AC

review.
It is observed in Figure 1 that the study of KAP of food handlers on food
safety is an emerging research topic. From 36 studies included, 18 were
published between 2013 and 2017. This growing interest of the scientific
community corroborates two main hypotheses: 1) the behavior of food handlers
relates directly to the FBD due to inadequate practices in: hand, equipment and
utensils hygiene; maintenance of temperature of food ready for consumption;
cooking temperature; and thawing (Chan & Chan, 2008). Such improper
practices indicate that food handlers are the main responsible of FBD outbreaks
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(FDA, 2009; Lima, Loiko, Casarin, Tondo, 2013), therefore, the food safety
training to food handlers is one of the most critical interventions on FBD
prevention (WHO, 2013); 2) Even with the development of new technologies
and management systems of quality, the incidence of FBD has not reduced and
can be noticed even the emergence of some pathogens such as
Campylobacter, Shigella and Cryptosporidium (Nyachuba, 2010).

PT
Figure 1 - Overview of publication´s number on knowledge, attitudes and
practices of food handlers in food safety, published each year between the

RI
years 2000 and February 2017.

SC
The need to evaluate the training from the point of view of the food handler,
taking into account the beliefs and behavior, is due to the assumption that the
NU
traditional training cannot be transformative, in which the handler does not apply
the knowledge gained in their practices (Ehiri, Morris & McEwen, 1997; Ansari-
MA

Lari et al., 2010; Siow & Sani, 2011; Ko, 2013). So these assessments can be
used as diagnostic strategies for planning effective and specific training
programs for each handler in a particular function (Zanin, Da Cunha, Stedefeldt
D

& Capriles, 2015).


E
PT

3.2 Characteristics of included studies: Knowledge, Attitudes and


Practices and their relationships with training in food safety
CE

Table 1 shows the main characteristics of each article included in this review.
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Table 1 - Description of the studies that relate knowledge, attitudes and practices of food handlers with training in food safety.

Country and Characteristics of the


Reference year of food handler and Approaches related to training Main conclusions
publication food service

P T
- There is a difference between training and

Dudeja et al.
India n=264
- Meaningful and focused trainings can contribute to
improve both the safety and quality of food.
R I teaching food handlers.
- Attitudes are a reflection of traditional beliefs,
which can serve as obstacles to appropriate
(2017) Tertiary care hospital.
is inconclusive.

S C
- Research on food safety training of food handlers
practices.
- Positive attitudes can improve practice and
vice versa.

N U
- Training for caterers has been shown to improve
food safety knowledge and hygiene awareness and - Good knowledge levels, attitudes and self-

A
n=265 may result in improved food safety practices. reported practices.
Rebouças et Brazil
25% with no training. - It’s necessary a recycling of these trainings. - Although some self-reporting practices have
al. (2017)
Hotels' restaurants.
M
- The participation of the handlers in training,
showing in this way the creation of a positive culture
been adequate, there were divergences in
observed practice.

n=180
100% with no training.
D
among the handlers.

E
- Training should therefore be provided which

PT
Various points of the integrates basic hygiene and new food safety - The food safety and hygiene knowledge of
seafood distribution programs conforming to national regulations. seafood distributors was poor.
Vietnam
Luu et al.
(2017)
E
chain (30 middlemen
traders, 60 seafood

C
handlers, and 70
- Training should be: 1) more practical (i.e.
demonstrations) rather than theoretical. 2) the
provision of guidance and information in the form of
- Most of the participants in this study exhibited
poor fish handling practices.

Pacholewicz Netherlands A C retailers).

n=26
42% with no training.
manuals, short booklets, or videos.

- Training did not influence the knowledge score.


- Food handlers had knowledge about their
tasks, but they have not always implemented it
et al. (2016)
Two slaughterhouses. into practice and attitude.
n=87 - Management should provide motivation and - Food safety knowledge level of food handlers
Al-Shabib et Saudi Arabia 5.7% with no training. support to the staff engaged in food handling for the will influence their attitudes and self-reported
al. (2016) 2 restaurants and 5 success of food safety training. practices in handling food safely.
canteens (University). - Trainings and materials should be provided and - Even though the knowledge, attitude and
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frequent training programs should be organized to self-reported practice level of the food handlers
improve the attitude, knowledge and expertise of was satisfactory, some of the hygiene aspects
the food handlers. need to be stressed.
- Education and food safety training should be
provided frequently to the food service staff in order
to minimize foodborne hazards.
- The training must be risk-based with

P T
Kunadu et Ghana
n=278
With no percentage of
training.
consequences of failure clearly expressed and
understood at all levels.
- The negative attitudes would however advocate
R I - Insufficient food safety knowledge and

C
practices.
al. (2016) Food services motivation and training; not just education.
(hospital, schools and
prison).
S
- Techniques employed in training must also be
tailored to accommodate the low education levels of
the food handlers.
U
Samapundo
et al.
Vietnam
(2016)
n=40
95% with no training.
Street food vendor
N
- The training of street food vendors should be

A
prioritized in governments efforts to improve the
- Poor food safety knowledge levels, attitudes
and unhygienic practices.
- Regulations governing street food safety has
(four districts).
M
safety of street foods. not yet transformed the knowledge, attitudes
and practices of the food handler.

Faour‐Klingb Lebanon
n=80
46% with no training.
E D
- Critical need for food safety education and
technical guidance fostered by synergistic
participation of the private and public sector to
- Substantial gaps in their knowledge and self-
reported practices.
eil et al. (2015) 50 food service
establishments.

P T support food handlers in small and medium sized


enterprises.
- Food handlers' attitudes were not translate
into self-reported practice.

E
- The conditions in which street food vendors
n=80 operate are mostly unacceptable from a food

C
- Food vendors trained had a significantly greater
78.7% with no training. safety point of view.
Samapundo Haiti food safety attitudes than untrained.
et al.
20
(2015)

A C
Street food vendors
(four different
communes).
- There is an urgent need to organize formal
training in food hygiene and food safety.
- Trained handlers have a higher knowledge
and attitudes score than the not trained ones.
- Knowledge and attitudes have not been
translated into observed practices.
n=909 - Food-handlers' suggestions for training needs
- KAP of food-handlers were poor.
3.1% with no training. included: appropriate location of the training venue
Vietnam - Positive effects of educational level on
Vo et al. 26 canteens of at the work place involvement of managers, fewer
(2015) knowledge and practices, although knowledge
factories and 40 trainees per course, more practical exercises, and
alone was not enough to change practices.
canteens of schools. longer course duration, be more interactive with
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more visuals and less text.


- The health belief model should be applied during
training courses.

n=193

T
66.3% with no training. - KAP combined with the Theory of Planned
- Attitude score and the age of the worker were
Seafood handlers Behavior can support the development of
Zanin et al.
Brazil
(2015)
(fishery and
warehouse workers
appropriate training programs.
- Long periods without training can negatively affect
I P
related to the self-reported practice scores.
- Knowledge and attitudes did not always
from 2 different
states).
n=171
the sanitary conditions.

C R result in appropriate self-reported practices.

Iiu et al. China (2015)


34% with no training.
22 food services
U S
- The knowledge showed failure in training;
interviewees did not receive necessary information.
- Training should be more selective.
- Knowledge and attitudes were not translated
into self-reported practices.

N
(resort).
n=183
Da Cunha et
al.
Brazil
(2014a)
31.7% with no training.
119 food services
(Diversified).
M A
- The investment in the theoretical training seems to
be insufficient to ensure appropriate practices.
- Knowledge did not translate into attitudes,
self-reported and observed practices.

Malaysia
n=112
73.2% with no training.
E D
- The training program should not only be
theoretical but also practical, targeting the activities
- The knowledge score was low.
- The knowledge influenced the attitudes and
Sani & Siow
(2014) 11 food services
(University).
P T of handlers.
- The training should be performed for all handlers
to minimize the dangers of FBD.
self-reported practices, however, handlers can
not apply the knowledge learned in appropriate
self-reported practices in some subjects.

McIntyre et Canada
C
n=698
28.52% with no
E - Importance of ongoing training.
- The practical training in the workplace can - Trained handlers had better scores for
al. (2013)

A Ctraining.
Various food services.
n=85
increase knowledge and appropriate practices.
- The knowledge acquired by training is lost over
time.
attitudes and self-reported practices that those
untrained.

- No difference between trained and untrained


Malaysia 35.3% with no training. food handlers.
Tan et al. - Hands-on training should be implemented.
(2013) 38 food services - Weak correlations were observed between
(Public schools). knowledge, attitudes and practices.
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n=365 -The perception of risk increases with participation


- The intervention increased the adequacy of
Da Cunha et Brazil 100% with training. in mandatory training.
schools in legal requirements related to
al. (2013) 68 food services - Proper training helps to achieve adequacy in food
hygiene.
(Public schools). service.

n=421
With no percentage of
- Training is essential to ensure the perception and
T
- Knowledge is flawed, indicating that food

P
Ko
Taiwan
(2013)
training.
Restaurants with
knowledge.
- Although training increases knowledge, it does not
always result in positive behavior change.
R I handlers believe that training is not important.
- Attitude is the mediator between knowledge
and practice (self-reported).

SC
certification HACCP.
- More specific training programs should be set to - Low knowledge scores.
n=166
the handlers. - Practices (self-reported) of inappropriate
7.8% with no training.
Soares et al. Brazil (2012)
90 food services
(Public schools).
methodologies.
N U
- It is necessary to evaluate the impact of the
knowledge acquired in training to develop specific
handling are not always the results of low
education, it may simply be reflecting a
dominant practice.

Abdul-
Mutalib et al.
Malaysia
(2012)
n=64
With no percentage of
training.
M A
- Training should strengthen the knowledge of food
handlers, avoiding irrelevant information.
- Having proper knowledge can lead to good
attitudes and even good practice (self-
reported).
Various food services.
n=209
With no frequent
E D - Knowledge was not translated into observed
Bassyouni et
al.
Egypt
(2012)
training.

P
Four food services T - The training prior to work starting and continuous
observation are important to ensure food safety.
practices, but it was translated into self-
reported practices for some themes.

E
(University canteens).
- Training is the key to food hygiene.

C
- Training seemed to be a strong predictor of
- Training, instruction and adequate supervision
n= 361 attitudes and practices in food safety.

C
Rahman et Malaysia increase the potential of food vendors.
29.6% with no training. - Knowledge was not converted into self-
al. (2012) - Monitoring, training of basic principles of food

A
Street food vendors.

n=105
safety and the continued microbiological
surveillance are essential to optimize food hygiene.
reported practices, even to the trained
handlers.
- Handlers find training is insufficient /
Garayoa et Spain 58.1% with no training. - Perform specific training for each handler repetitive.
al. (2011) 20 food services according to their activities. - Knowledge has not translated into self-
(Diverse cuisines). reported practices.
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- Food handlers should attend specific training - 80% of food handlers had insufficient
n=92
Cuprasitrut Thailand related to the basic principles of food safety and knowledge, negative attitudes and inadequate
79.3% with no training.
et al. (2011) personal hygiene rules to improve their practices in self-reported practices.
68 food services.
food handling. - Knowledge correlated with practice.
- Knowledge and self-reported practices can
Choudhury India
n=80
With no percentage of - Training interventions should be designed to inflict
T
improve with the transmission of an interactive

P
I
training.
et al. (2011) training. maximum interest and response of food handlers.
- Post-training: improved knowledge and self-

R
Various food services.
reported practices.

SC
n=65
72.3% with no training. - Training improves knowledge but does not always - The handlers had an average score of
Malaysia
Siow & Sani Cafeterias and produce a positive change in attitudes. knowledge, most had positive attitudes and an
(2011)
canteens of a
university.

N U
- Training should encourage positive attitudes. average score of self-reported practices.

Ansari-Lari
et al.
Iran
(2010)
n=97
6% with no training.
1 Meat Processing
Plant. M A
- Increased knowledge does not always result in
positive behavior change.
- Training must be evaluated to guarantee its
effectiveness.
- Despite adequate knowledge and positive
attitudes, the self-reported practices are not
acceptable.

n=502
19.7% with no training.
E D
- Food safety can be a field in which education and
- The knowledge in food hygiene is insufficient
to promote positive attitudes and safe
Buccheri et
al.
Italy
(2010)
10 food services

P
(clinics of mentalT training can be organized in order to integrate the
behavioral sciences to public health.
behaviors (self-reported practices).
- Continued training with an alternative

C
n=73 E
illnesses).

- The discrepancy between attitudes and practices


strategy.

- Gap in knowledge, positive attitudes.


Tokuc et al.
Turkey
(2009)

A C
100% with no training.
Three food services
(hospitals).
can be a result of lack of training, taken in attitudes
and safe behaviors (empirical) with household tools.
- Attitudes did not translate into self-reported
practices.

- Approximately half of the food handlers had


n=430
- A program of health education is an essential low knowledge scores and inadequate self-
Malaysia With no percentage of
Naing et al. component to improve knowledge and practices reported practices.
(2007) training.
related to FBD and food safety. - Most handlers had positive attitudes and
Various food services.
beliefs.
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n=100
- The reliability assessment of the KAP
Naing, Zain, Malaysia With no percentage of - The questionnaire shows good reliability for
questionnaire helps planning health education
& Abdullah (2007) training. the evaluation of KAP (self-reported practices).
programs for food handlers.
Various food services.
n=764
Bas et al.
Turkey 47.8% with no training.
- The effectiveness of hygiene training is uncertain.
- Training in food safety should be offered to all

P T
- Knowledge gap in food safety.
- Low scores of self-reported attitudes and

I
(2006) 109 various food
handlers continuously. practices.
services.
n=254
R
SC
- The difference between beliefs and practices - Gap in knowledge.
Askarian et Iran 37.9% with no training.
implies the fact that some people, even trained, do - Beliefs remained and there was no
al. (2004) Food services
not understand the real purpose of training. improvement in self-reported practices.

U
(hospitals).
n=164 - Foodservice employees had a significant amount

N
- Although food safety knowledge scores were
EUA 58.5% with no training. of food safety knowledge, and employees with food
Sneed et al. high, food-handling practices were not always

Zain & Naing


(2004)

Malaysia
40 assisted-living
facilities.
n=430
57.2% with no training. M A
safety certification scored higher than those with no
certification, respectively.
- Training programs need to be evaluated to ensure
consistent with accepted standards.
- Low score of knowledge, positive attitudes,
lack of adequate self-reported practices in

D
(2002) effectiveness.
Various food services. daily activities.

n=382
With no percentage of
T E - Young and trained handlers have more
knowledge.
- Positive attitudes in older handlers in
Angelillo et
al.
Italy
(2001)
training.
Food services
(hospitals).
E P - To ensure the implementation of HACCP rigorous
training should be implemented.
hospitals with fewer beds.
- Attitudes are not transformed into self-
reported practices in some areas of food

C C safety.

A
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In seven selected articles, the authors concluded that attitudes were not
translated into practices (Angelillo et al., 2000; Zain & Naing, 2002; Askarian,
Kabir, Aminbaig, Memish & Jafari, 2004; Naing et al., 2007; Tokuç, Ekuklu,
Berberoglu, Bilge & Dedeler, 2009; Faour-Klingbeil, Kuri & Tood, 2015;
Samapundo, Climat, Xhaferi & Devlieghere, 2015); four studies stated that
knowledge has not translated into practices (Garayoa, Vitas, Díez-Leturia &
García-Jalon 2011; Bassyouni, El-Sherbiny, Hefzy & Wegdan, 2012; Rahman,

PT
Arif, Bakar & Tambi, 2012; Vo, Le, Le, Minh & Nuorti, 2015); three that
knowledge has translated neither into attitudes nor into practices (Buccheri,

RI
Mammina, Giammanco, Giammanco & Casuccio, 2010; Da Cunha et al.,
2014a; Pacholewicz et al., 2016); and in four others the knowledge and

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attitudes has not translated into practice (Ansari-Lari et al., 2010; Iiu et al.,
2015; Samapundo et al., 2015; Zanin et al., 2015). i.e. 50% of the articles
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selected asserted that there was no translation of knowledge into attitudes /
practices or attitudes into practices.
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These results, while interesting, are not new. Ehiri and Morris (1996), cited
training that does not change food-handling practices. Many aspects influence
the change of food safety practices e.g. the strategy approach used to train/
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educate food handlers (Egan et al., 2007); physical structure of food service
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(Tannenbaum & Yukl, 1992); place where the training has been conducted
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(Rennie, 1994); mandatory versus voluntary attendance of training (Cotterchio,


Gunn, Coffill, Tormey & Barry, 1998 ) aspects related to food safety culture
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(leadership, communication, commitment, environment and risk perception)


(Griffith, Livesey & Clayton, 2010) and other.
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Codex alimentarius, and its documents, are an important reference for


professionals and public policy stakeholders. The Codex Alimentarius (2013)
recommends that all people involved with food must be aware of their role and
responsibility in food safety. Food handlers must have the necessary knowledge
and skills to handle food hygienically. Additionally, food operation managers
and supervisors must have knowledge of food hygiene practices to assess the
potential risks of FBD, and they should make decisions to prevent its
occurrence (Codex Alimentarius, 2013). Although the Codex alimentarius Food
Hygiene basics text recommends the review and evaluation of the training
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14

programme, few guidelines are indicated in this context. Such factors may
reinforce the understanding that theoretical training solves the problems of good
manufacturing practices in food services.
In six studies, the authors concluded that the knowledge level was
equivalent with practices (Siow & Sani, 2011; Cuprasitrut, Srisorrachatr & Malai,
2011; Tan, Bakar, Karim, Lee & Mahyudin, 2013; Sani & Siow, 2014; Kunadu,
Ofosu, Aboagye & Tano-Debrah, 2016; Luu, Davies & Dunne, 2017). However,

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in three of them, they found inadequate knowledge and practices in some
subjects (Cuprasitrut et al., 2011; Tan et al., 2013; Sani & Siow, 2014). The

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transformation of knowledge into practice runs through several aspects such:
experience, risk perceptions, attitudes and emotions (Wachinger, Renn, Begg

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and Kuhlicke, 2013). The individual tends to consider a decision, practice and
practice mitigation intuitively based on the risk that a decision or action leads to
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or aggravates a negative event, which is also called perceived risk (Slovic,
1987). Risk judgments involve what people think and how they feel about this
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risk, strongly affecting food handler behavior (Da Cunha et al., 2015). Risk
perception is subjective and based on experience, and understanding it is
important to the success of food safety communication and the absorption of
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new technologies (Behrens et al., 2010).


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In other two articles, food handlers surveyed reported that training was
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not important (Garayoa et al., 2011; Ko, 2013). This affirmation may be
dangerous. Training is an effective tool for improving knowledge, as noted
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(table 1). As knowledge is important for adequate practices, so it is not


recommended that training be ceased (Da Cunha et al., 2014a). The main
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problem is ignoring all the aspects aforementioned that affects the translation of
knowledge into practice.
It was observed in two intervention studies through training, that the
trained food handlers had better scores practices (Choudhury, Mahanta,
Goswami & Mazumder, 2011; McIntyre et al., 2013). However, in the study of
McIntyre et al. (2013) and Samapundo et al. (2015) trained handlers had higher
scores of attitudes, and the study of Choudhury et al. (2011) they had higher
scores of knowledge than those not trained. This knowledge allied to attitudes
may act as precursor to behavioral change (Mullan, Wong & Kothe, 2010).
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15

Positive attitudes are a necessary factor for the transformation of knowledge


into appropriate practices by food handlers, being a mediator between
knowledge and practices (Ko, 2013). A person's intentions and his beliefs about
food safety are influenced by two key factors. In the first, the level of a person's
intent is greater if he has a positive attitude towards the behavior. In the second,
the level of intent will be greater if he is motivated to act in accordance with
social norms (Yiannas, 2009). To adapt this motivation to the workplace,

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Yiannas (2009) identifies some relevant actions, such as valuing people,
recognizing the improvement of attitudes; encouraging initiatives, delegating

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authority and conducting evaluations.
The last aspect of KAP triad is practice. The assessment practices can be

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performed in two ways, from questionnaires, called self-reported practice, and
from the observation of the work of the food handler, called the observed
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practices. Of the selected articles, 26 assessed the self-reported practices,
eight evaluated the observed practices and three assessed both self-reported
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practices and the observed practices. The self-reported practice may pose as
bias in the research by considering the food handler can present an excessively
positive and biased view of their practices (Da Cunha, Stedefeldt & De Rosso,
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2014b).
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It is recommended using the observed practices in order to evaluate the


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food safety performance, and the self-reported practices to assess perceptions


and behavior. Both can indicate the weaknesses of good practices in food
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services, however, their interpretation should be distinct, not being


interchangeable evaluations.
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The good satisfaction with the job also been related with introduced
appropriate practices (Rebouças, Santiago, Martins, Menezes, Araújo, &
Almeida, 2017). Such practices are a major factor in food safety, nevertheless
converting knowledge into adequate practices is a complex process, but it can
have the effect of reducing the risk of FBD and consequently the health care of
the consumer (Sani & Siow, 2014; Iiu et al., 2015).
Most of the studies, covered in this review, evaluate KAP and are limited to
these scores, characterizing them with the solution (or cause) of the negligence
of good manufacturing practices. However, KAP scores may be only used as
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16

diagnostic to plan interventions, showing the need for advancement in these


studies to propose the diagnosis through other variables and more efficient
training for food handlers.
The significant presence of knowledge is a motivation for adequate
practices and justify the necessity of training. Knowledge allows the handler to
modify its practice since he has motivation to change his behavior (Bas et al.,
2006). Therefore, the training is an urgent need, especially to the not trained

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handlers (Samapundo et a., 2015; Samapundo, Thanh, Xhaferi & Devlieghere,
2016) and the participation of the handlers in training, show the creation of a

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positive culture among the handlers (Rebouças et al., 2017).
Ko (2013) evaluated handlers who believed that training was flawed, and

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Garayoa et al. (2011) evaluated handlers who considered training insufficient or
repetitive. Thus, the techniques used for the training of food handlers should be
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proposed to minimize theoretical concepts (Medeiros et al., 2011; Luu et al.,
2017), since they seem to be insufficient, because are not related to the
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attitudes, self-reported practices and observed practices by food handlers (Da


Cunha et al., 2014a).
According to the selected studies, effective training is essential to improve
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knowledge, perceptions (Naing et al., 2007; Ko, 2013), and should be offered to
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all food handlers (Sani & Siow, 2014), including workers by all sector of food
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service, whereas all productive process, but it needs to be specific according to


the function that the food handler carries (Garayoa et al., 2011; Cuprasitrut et
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al., 2011), minimizing an asymmetry of information that can lead to market


failures.
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Train food handlers at the workplace (McIntyre et al., 2013) is a way to


approximated the theory of the practice and to ensure that they will know to do
in their workplace. Assuming that it is never too late to learn and that there is
always something to be learned training needs to be offered continuously (Bas
et al., 2006; Rahman et al., 2012; McIntyre et al., 2013; Zanin et al., 2015, Al-
Shabib, Mosilhey & Husainet, 2016); and cause as much interest in food
handlers (Choudhury et al., 2011).
An effective model of training is selective, strengthens the knowledge, avoid
irrelevant information (Abdul-Mutalib et al., 2012; Iiu et al., 2015); accommodate
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17

the education levels of the food handlers (Kunadu, Ofosu, Aboisagye & Tano-
Debrah, 2016); use languages according to food handler ethnicity and
encourage positive attitudes (Sani & Siow, 2014). The content of the
information, the form of communication and who communicates are
determinants.
Food services are a multifaceted scenario containing complex situations in
which the risks are multifactorial and associated with some uncertainty and/or

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ambiguity. In this sense, contextual and environmental diversity may reflect the
intensity of risk that is related to exposure to hazards social, economic, and

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political environment. Thus, the risk-based training with consequences of
failure clearly expressed is fundamental (Kunadu et al., 2016).

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Integrating basic hygiene and new food safety programs according to
national regulations (Luu et al., 2017), since basic hygiene is a prerequisite of
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any food safety program, is a way of the training to meet the different
complexities of food services. The training should be continuously assessed
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(Zain & Naing, 2002; Ansari-Lari et al., 2010; Soares et al., 2012), creating a
feedback.
The management should encourage and motivate the staff through practical
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training ensuring safe practices in food handling (Tan et al., 2013; Da Cunha et
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al., 2014a; Sani & Siow,2014Al-Shabib et al., 2016).


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Figure 2 illustrates several of these recommendations for effective training.


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Figure 2 - Factors for planning a program of training with efficient application of


knowledge, attitudes and practices.
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3.3 Beyond theoretical trainings

Most current training in food safety uses the method of providing the
information, following the model of KAP, widely criticized and with perceived
limitations (Ehiri & Morris, 1996). However, in this review 50% of the selected
studies reported that knowledge was not translated into attitudes or practices
change, presenting its main disadvantage point and exemplifying the model's
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18

criticizes and limitations. These limitations can be influenced negatively in the


planning of an effective training.
A major flaw of theoretical training based on KAP is the assumption that the
information received by people is translated into practices and behavior. The
techniques used to train food handlers should be reviewed by minimizing
theoretical concepts and lectures, a widely used feature (Medeiros et al., 2011).
Some motivational mechanism is needed to generate positive attitudes to

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hygiene and sanitary food handling (Ehiri et al., 1997; Ko, 2013). The trainer
and managers should provide motivation and self-efficacy to food handlers

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(Seaman & Eves, 2006; Stedefeldt, Zanin, Da Cunha, De Rosso, Capriles, &
Saccol, 2015; Al-Shabib et al., 2016), these attributes will ensure that even

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when there is no supervision, all good practices are carried out.
Some factors have been discussed as important to improve food safety
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performance: e.g. presence of trained food handlers (Hislop & Shaw, 2009;
Choudhury et al., 2011); presence of a qualified manager to supervise food
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safety and to lead (Cotterchio et al., 1998; Kassa, Silverman & Baroudi, 2010),
so that critical points and risk situations are observed there is a need to qualify
the manager and knowledge of the legislation; suitable environment
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(Tannenbaum & Yukl, 1992; Tracey, Tannenbaum & Kavanagh, 1995; Da


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Cunha et al., 2013; Stedefeldt et al., 2015) are minimum requirements for food
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safety.
The consequences of FBD in the risk perspective must be worked and
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establishing goals needs to be present to the food handlers (Stedefeldt et al.,


2015). Some of these aspects were considered in the selected studies. This
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factor may hinder the real effectiveness (or ineffectiveness) of training based on
KAP model.
Some food hygiene training models have been created and tested based
on permanent strategies. Da Cunha et al. (2013) established and tested a
training model with school food handlers. This model was applied during two
years and three main strategies were used: 1) theoretical training every six
months, 2) implementation of action plans in situ every three weeks and 3)
weekly visits to motivate food handlers and monitor good practices. The
proposed intervention improved school compliance with the food safety laws.
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19

Dudeja, Singh, Sahni, Kaur & Goel (2017) adopted a training methodology
with an emotional content and personal touch based on booklet, short films,
lectures, posters display concluding that was useful in improving the knowledge,
creating a positive attitude and enhancing the food safety practices of food
handlers. According to the authors (Dudeja et al., 2017) and with the
discussions presented in this article food handlers training is a means but not
an end in itself because training does not always lead to improved practices

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Training strategies can be challenging since, as reported, many factors
can direct influence the training efficacy and thus, the food safety practices. As

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example, foodservices may hire temporary workers, low paid and with low
education level (Cavalli & Salay, 2007), factors that undermine change in food

SC
safety practices (Mortlock, Peters & Griffith, 2000).
The psychosocial aspects of food safety, namely the beliefs, self-efficacy,
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locus of control and stage of change, have been studied in the food safety field
(Byrd-Bredbenner et al., 2007a, b). In considering the above, researchers have
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studied ways to identify the nuances of behavior and their theories and to
propose diagnostic strategies and training to improve food handler practices, in
addition to the attending health legislation. From this perspective, carefully
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considering the pedagogical approach to adopt is fundamental. All educational


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activity is thought to obey the purposes of social, cultural, political and economic
PT

development. Consequently, this activity responds to certain interests. It is


therefore maintained by a philosophy of education in space and time (Bezerra,
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Mancuso & Heitz, 2014).


Methodological approaches designed to evaluate only the scores of
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knowledge, attitudes and self-reported practices after training may induce


conclusions that do not address the full complexity of food safety. In new
studies, researchers should consider the assessment of different aspects of
food handling to contrast with KAP scores. In this context, researchers should
consider KAP scores will be independent variables that may affect and interact
with food safety practices.
As final recommendation, a review of important topics are listed. The
data obtained on this topic provide suggestions that may be fruitful for practical
improvement or that can maximize the following intervention strategies:
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20

1) The techniques used in training should be reviewed by minimizing


theoretical concepts, a widely used feature (Medeiros et al., 2011). 2) Train food
handlers in the workplace to improve their understanding of procedures. The
tutor can reinforce theoretical ideas in a practical manner (Da Cunha et al.,
2013; Rennie, 1994).
3) Involve the owner of the property or manager/supervisor in
interventions regarding good practices. A supervisor with knowledge can assist

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in monitoring and correcting improper practices (Egan et al., 2007; Seaman &
Eves, 2006).

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4) Provide a suitable environment, with the necessary resources,
equipment and utensils for the implementation of good manufacturing practices

SC
(Tannenbaum and Yukl, 1992; Tracey et al., 1995).
5) Provide motivation. Feelings such as motivation and self-efficacy play
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important roles in enhancing training and the adoption of adequate practices
(Seaman & Eves, 2006).
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6) Establish goals and present them to the group. A goal, when feasible,
may motivate the fulfillment of tasks (Ray et al., 1997).
7) Evaluate the impact of the acquired knowledge. The evaluation of
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results allows for the development of their own training methodologies (Garayoa
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et al., 2012; Soares et al., 2012).


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8) Select the content of the training. Irrelevant information reduces the


interest of the handler (Abdul-Muttalib et al., 2012).
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Some factors can negatively affect the impact of training and


interventions performed in food services, such as hiring employees with a low
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socioeconomic status and low education, a high employee turnover, the cost of
interventions for food safety and dissatisfaction with pay (Mortlock et al., 2000;
Seaman & Eves, 2006). Therefore, these factors must be evaluated with the
intention to cause changes. For example, improving the socioeconomic
situation and decreasing the worker turnover.

4 Conclusion
In general, in the studies included in this paper is discussed that there is no
translation of knowledge into attitudes / practices or attitudes into practices after
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21

training. Some satisfactory results were observed in this triad when more
advanced techniques of education and training were used.

Knowledge, attitudes and practices of food handlers are important for


identifying how efficient training in food safety is allowing prioritize actions in
planning training. These evaluations are important to detect that the
assessment be applied before and after training. However, the evaluation of

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KAP is limited to these answers and not to deliver refined conclusions about the
behavior of the food handler and on action strategies related to psychological

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factors that affect practices.
The researcher’s apprehension that the evaluation of KAP is the first step to

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understand the food handler´s point of view. After this evaluation other
diagnostic strategies become necessary to enhance this understanding,
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especially considering the gap in the studies included. Consequently models
and longitudinal strategies, with environmental suitability, considering
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psychological, social factors and experience that shapes the behavior of food
handlers can be designed in the hope of promoting food safety and minimize
the causative factors of FBD.
E D
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Funding
“This research did not receive any specific grant from funding agencies in the
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public, commercial, or not-for-profit sectors”.


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22

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Figure 1
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Studies that adressed only "knowledge" ou "attitude" or "practice", or a combination of these two terms

Studies that adressed the triad "knowledge, attitudes and practices" of food handlers regarding food safety (included in this

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Figure 2

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Highlights

 Majority of KAP surveys were conducted in developing countries.


 There was no proper translation of knowledge/attitudes into
attitudes/practice.
 Evaluation of KAP is the first step to understand the food handlers´ point
of view.

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 Studies with evaluations of observed practice are still scarce.
 KAP are important for identifying how efficient training in food safety is.

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