FOOD SAFETY KNOWLEDGE AND PRACTICES OF NURSING STUDENTS

Abstract

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

Headnote

ABSTRACT

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

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

INTRODUCTION

Food safety is a global health goal and foodborne diseases are a major health issue (VELUSAMY et al, 2010). Foodborne diseases represent a widespread and growing public health problem, in both developed and developing countries. This problem, however, has more impact on health and economy in developing countries but no reliable data are available (WHO, 2007). The major food safety risks are not eating a healthy diet and failure to avoid foodborne diseases (CHASSY, 2010). Foodborne diseases caused by microbial pathogens, biotoxins, and chemical contaminants in food represent serious threats to the health of thousands of millions of people (FAO and WHO, 2008). It is difficult to estimate the incidence of foodborne diseases worldwide because most cases of the disease cannot be recorded. Within two decades, the human population is predicted to reach 8.5 billion, 80% of whom are expected to be in developing countries (WHO, 1997). In the industrialised countries up to 10% of the population may suffer annually from foodborne diseases (WHO, 1998; KAFERSTEIN and ABDULSSAULAM, 1999). WHO estimated that in 2005 1.8 million people worldwide died from the effects of foodborne diseases (WHO, 2005). It has been estimated that foodborne diseases cause approximately 76 million illnesses, 325,000 hospitalisations and 5000 deaths in the United States each year (MEAD and SLUTSKER, 1999). In Turkey, according to the Ministry of Health (2006), 26,772 people were hospitalised because of foodborne diseases. Some 23,901 Salmonella typhii infections, 429 Salmonella paratyphii infections, 21,068 cases of dysentery and 8,824 cases of hepatitis A occurred in 2004. Since the reporting of foodborne diseases to a specified agency is not obligatory in Turkey, data on foodborne infections are inaccurate (WHO, 2004).

Institutions and professions, which are in constant interaction with the public, are reliable resources to persuade people to adopt desirable habits as regards food safety. Therefore nurses working in the health sector can be regarded as a potential source to be used for this purpose, which in turn makes their information level in terms of food safety crucial for several reasons. The major task of public health professionals is to deal with public awareness. As health professionals, nurses should have appropriate knowledge about adequate and balanced nutrition as well as food safety (BUCCHERI et al, 2007). The importance of safe food for hospitalised patients and the detrimental effect that contaminated food could have on their recovery has been widely emphasised. Food safety in hospital may have unique features: many patients are more vulnerable than healthy subjects to microbiological and nutritional risks; large numbers of people can be exposed to infections and possible complications; gastroenteritis can impair digestion and absorption of nutrients; and the perception or fear about poor food hygiene practices might result in patients rejecting the meals supplied by the hospital catering service (BARRIE 1996; DEREA et al, 2008).

Further concern arises from the common use of nurses or domestic staff as food handlers, as they are not specifically trained about food hygiene and HACCP but can be engaged in the receipt, distribution and serving of readymade foods and supervision of these services (BUCCHERI et al, 2007). In Turkey, owing to the small number of dieticians in hospitals nurses are sometimes responsible for the distribution and serving of meals and helping patients to consume their meals properly.

The prevention of foodborne diseases requires all food consumers, especially nurses, to be taught about food handling practices. Prior to such education, however, it is important to identify the food safety issues relevant to nurses as consumers (JEVSNIK et al, 2008; OSAILI étal, 2011). In addition, education about food and nutrition issues at an early age influences the attitudes of youngsters and enhances the knowledge and skills required for them to understand contemporary issues related to food (LYTLE, 1995).

There is no education programme in Turkey for improving the food safety knowledge and practices of consumers in any age group or in schools, and assessing the basic knowledge of young consumers is essential for developing effective food safety programmes. To the best of our knowledge, limited studies focusing on nursing students have been conducted and there is no study concerning food safety knowledge of nursing students in Turkey and the world. Therefore, this study aimed at evaluating the perception of food safety by nursing students and the influence of food, personal and kitchen hygiene and safety education on the food safety knowledge, attitude and practices of nursing students.

METHOD

Design, sample and data collection

A cross-sectional study was conducted and the questionnaire was administered between March and June 2010 to assess food safety knowledge, practice and attitudes of nursing students in Ankara, the capital of Turkey. The study population constituted final-year students from five typical public universities and consisted of 739 nursing students whose ages were between 18 and 26. A structured questionnaire was self-administered by 739 students in the classroom environment and 68 1 were returned (92% return rate). After questionnaires which had missing values were eliminated, analyses were carried out on 662 (629 - 95% female, 33 - 5% male) valid questionnaires. In Turkey, nursing is largely perceived as a woman's profession, although in recent years men have also entered this profession. Therefore, the number of female nursing students participating in the study was greater than the number of male nursing students. The participants were informed about the subject, purpose and rules of the research. Students" consent was required prior to commencement of the study. Each participant signed a voluntary participation form and filled in the questionnaires in strict accordance with the Declaration of Helsinki (World Medical Association). The participants were informed about the subject and the purpose of the research.

INSTRUMENT

A structured questionnaire was designed to collect the research data. The questionnaire was administered to assess the food safety knowledge, food safety practices and food safety beliefs of the participants. The questionnaire was based on those used in earlier studies (SAMMARCO et al, 1997; HAAPALA and PROBART, 2004; SANLIER, 2009). The questionnaire was pilot-tested by 86 participants between March and April 20 10, resulting in minor modifications to the wording. The revised questionnaire was divided into five sections: demographic section (three questions), food safety knowledge (ten questions), personal/ kitchen hygiene knowledge (six questions), food handling practice (fourteen questions) and food safety attitude (eight questions).

The assessments of the answers were summarized as in the Appendix. Answers to the questions related to food safety knowledge were graded, one point being given for the right answer and zero for the wrong answer. The scale (which was related to safe food preparation practices) included a set of negative sentences (Table 2, statements, 1, 2, 5, 8, 10, and 1 1) in addition to the positive ones. Responses to the positive sentences were graded as follows: never 1, sometimes 2, always 3 s. In the negative sentences, the grades were assigned in reverse order.

The Cronbach alpha coefficient of internal consistency was used to estimate the reliability of the questionnaire. An alpha coefficient of 0.76 was considered to be acceptable for food safety knowledge.

A higher score represents a higher level of food safety, personal /kitchen hygiene knowledge, food handling practice and attitude. The questionnaire was given to the nursing students by the researchers in the face-to-face method and took approximately 15 min to complete. Students were informed about the purpose of the study and the importance of the reliability of their answers. To guarantee the anonymity of respondents and easy identification of questionnaires completed by individuals, identity numbers were randomly assigned to each questionnaire. Items in the questionnaire were explained when necessary and administered at one sitting as much as possible.

STATISTICAL ANALYSIS

AU statistical analyses were performed with SPSS (Statistical Package for Social Sciences) Version 15.0 (SPSS, Inc., Chicago, IL, USA). Descriptive statistics (mean and standard deviation, or frequency) were used for all variables. The independent sample t test was used to assess the difference between gender and age. Correlation analysis with Pearson's correlation coefficient was conducted to explore the associations between knowledge, practice and attitude. In all analyses, 5% significance levels were used.

RESULTS

Ninety-five per cent of participants were female and 5% were male. The mean age of the study population was 20.9±1.6 years (male: 21.0±1.3years, female: 20. 9± 1.7 years, respectively) and 55.4% of them were over 20 years old.

Whereas 77.2% of the participants replied that the statement 'the smell/appearance of foods that cause food poisoning is bad' was false, 78.2% of them replied that the statement 'there is no objection to the use of broken or cracked eggs' was true. Also, the majority of the participants rated as true the statements 'eggs cooked well can be kept at room temperature for more than two days', 'incorrect storage of foods does not constitute a hazard' and 'foods are hazardous that prepared with raw eggs' (75.7, 84.3, 65.1%, respectively). As regards the distribution of participant responses relating to food and personal hygiene knowledge, 38.5% of the nursing students rated as false the statement 'cigarette smoke blowing into the air contaminates food and the air with saliva', whereas 46.8% of them rated as true the statement 'wiping the cutting board with a disposable towel after use prevents bacterial growth'. The majority of the respondents rated as true the statements 'bacteria passed by hands to foods will cause toxins', 'hands should be dried with disposable towels' and 'surfaces should be cleaned before preparing foods' (82.8, 83.5, and 90.5%, respectively), (Table 1).

It was found that 26. 7% of the participants always/sometimes use dirty eggs without washing them carefully and 24.9% of them never touch cooked foods after handling raw foods. Sixtynine per cent of the participants stated that they never tasted milk to test it instead of checking the expiry date and 65.4% of them do not allow raw chicken, fish and meat to come into contact with each other. It was also found that 62.6% of the participants sometimes/always use outdoor milk after boiling it for half an hour and 56.2% of them stated that they thawed frozen meat always/ sometimes on countertops /radiators. The assessment of the attitudes concerning food safety practices showed that 44.5% of nursing students stated it was not important whether bought ready meals contained additives or not, 59.4% of them said shopping should always/sometimes be done at the supermarket because their products were of higher quality, 39.3% of them reported that sales promotions have an important impact on food purchasing decisions. The majority of the participants indicated that bloated cans should not be consumed (83.4%) and one should read the information and instructions on packaging (88. 1%) (Table 2). The comparison of scores according to various variables is given in Table 3. It was found that the female nursing students' food safety knowledge (t = -2.920, ? = 0.004), personal/kitchen hygiene knowledge (t = -3.327, ? = O.OOl), food handling practices (t = -3.095, ? = 0.002), attitudes towards food safety and total scores relating to food safety (t = -3.579, ? = O.OOO) were significantly higher than those of males (p < 0.05). In terms of age groups the differences were not statistically significant (p > 0.05) (Table 3).

As regards the correlation of food safety knowledge, personal/kitchen hygiene knowledge, food handling practice and food handling practice scores, the nursing students' personal /kitchen hygiene was found to be positively correlated with food safety knowledge score (r = 0.514, ? < O.Ol) and food handling practice (r = 0.484, ? < O.Ol) and food safety attitudes (r = 0. 178, ? < O.Ol), food handling practices were found to be positively correlated with food safety knowledge (r = 0.550, ? < 0.01) and food safety attitudes (r = 0.249, ? < 0.01), food safety attitudes were correlated with food safety knowledge (r = 0.202, ? < 0.01) and food handling practices (r=0.249, ? < 0.01) and total score were correlated with all study variables (p< 0.01) (Table 4).

DISCUSSION

Although the public is increasingly concerned about food-related risks, the rise in food poisoning cases suggests that people still make decisions about food consumption, food storage and food preparation that are less than ideal from a health and safety perspective (MCCARTHY et al., 2007). This study investigates the perception of food safety by nursing students and the impact of food, personal/kitchen hygiene and safety education on the food safety knowledge, attitude and practices of nursing students. The food safety knowledge, attitude, and behaviour of people play a major role in the incidence of foodborne diseases. Foodborne diseases are a widespread public health problem all over the world and often seen in both developed and less developed countries although the incidence varies from one country to another, depending on economic conditions and forms of social life (UNUSAN, 2007; SANLIER, 2009 and 2010). In response to the increasing number of foodborne diseases, governments all over the world are mtensifying their efforts to improve food safety (SUBBA et al, 2007).

Foodborne diseases have been associated with improper storage or reheating, food stored inappropriately and cross-contamination. These contributory factors result from lack of food hygiene awareness or implementation (WALKER et al, 2003; SANLIER, 2009; SCHÄFER étal., 1993). International studies have found that consumers often implement unsafe food-handling behaviours during domestic food preparation. Such malpractices need to be improved to reduce the risk and incidence of food poisoning (REDMOND and GRIFFITH, 2004; SANLIER et OÍ., 2010).

Consumers need knowledge of effective food handling skills and then need to be motivated to act on that knowledge as preconditions to behavioural change (BARANOWSKI et al, 2002).

Healthcare providers are a trusted source of information on health care and food safety practices. Health professions may play a substantial role in educating consumers on safe and appropriate behaviours (FEIN et al., 1995). Nurses in particular are considered to lead the community and are responsible for the development and administration of education about preventative health services for the public.

In this study it was found that the majority of nurse consumers do not have right information about food, personal and kitchen hygiene (Table 1, Table 2). For example, they did not give the right answer to statements like 'freezing does not kill the bacteria but only stops their reproduction', 'the inner temperature of poultry while cooking must be high', 'foods prepared with raw eggs have a potential risk', 'wiping cutting boards with disposable towels inhibits bacterial growth'.

A number of studies have demonstrated a lack of correlation between food hygiene training and improvements in food hygiene behaviour (ANSARI-LARI et al., 2009; SANLIER, 2009; SANLIER and TURKMEN, 2010). In this study nursing student practices and attitudes regarding food safety were found to be inappropriate (Table 2). Consumers' true perceptions of safe food, food safety knowledge, behaviour, attitudes and practices are important. The results of consumer studies concerning food safety knowledge and practices have shown that consumers are aware of and are thinking about food safety, although there are also many gaps in food safety knowledge and practices that could result in foodborne diseases (BADRIE et al, 2006; RASPOR et al, 2006; JEVSNIK et a?., 2008).

Surveys have produced inconsistent results with regard to the relation between food safety behaviours and education level, some risky practices being more common at higher levels of education and income (SHIFERAW et al, 2000; SANLIER et a?., 2010). According to the studies carried out in Turkey, food hygiene knowledge, attitude and perception scores are higher in women than men, higher in those aged 45 and older, higher in health areas than social areas, and college graduates have greater knowledge of food safety but lower scores at the same time (UNUSAN, 2007; SANLIER, 2009). The present study supports earlier findings (Tables 3 and 4). Studies have suggested that education and income are associated with attitudes towards food safety (BREWER and PRESTAT, 2007; STINSON et al, 2008; SUBBA étal, 2007; ÖZBILGEN, 2010). YARROW et al (2009) stated that food safety beliefs, attitudes, knowledge and practices could change through educational intervention. SAMMARCO et al (1997) indicated that consumers do not have enough knowledge and have improper practices related to personal hygiene, food handling and food storage and even basic and simple knowledge about detergents, disinfectants and sterilisation is inadequate. Findings from our study suggest that improper practices, such as using dirty eggs without careful washing and thawing frozen meat at room temperature, are widespread among the respondents. Similar behaviours are described in several previous studies and confirm that cross-contamination is a poorly perceived food safety issue (ANGELILLO et al, 2001; ALTEKRUSE et al, 1999; SHIFERAW étal, 2000).

In this study, a statistically significant correlation was found between nursing students' food hygiene, personal/kitchen hygiene knowledge, food handling practices, food safety attitudes and the total score (p<0.01). Improper practices and inadequate knowledge and perception of nursing students' were identified in the study (Table 4). Results strongly emphasise the need for basic food safety education for nurses who are non-professional food handlers involved in hospital food service functions.

The results obtained from this study revealed the need for consumer education regarding safe food handling practices from the point of purchase to the home, as well as within the home. We have to educate nurse consumers so that they can cope with all eventualities in the field of food safety on a dally basis (RASPOR et al, 2006). The attitudes of consumers towards food safety and their practices concerning food are themes of interest to food producers and retailers, public authorities and health educators (WlLCOCKY et al, 2004; JEVSNIK et al., 2008) Nurses' consumer education should target safe practices in food hygiene, causative foodborne diseases and agents, food-handling concepts such as cross-contamination, and the principles of HACCP, ISO 22000 as applied to health and food education in nursing school programmes (WHO, 2000; BADRIE et al, 2006). School and university settings would be the best places to reach young people and teach them key food safety concepts.

LIMITATIONS OF THE STUDY

Because the population of this study consisted of nursing students from central Turkey, the results cannot be generalized to all nurses or to all ages. Although the reliability coefficient was found to be high, interpretation of the results is limited owing to responses being selfreported and prone to bias by the subjects. Instrument validation for all university students through more testing and observational studies is needed.

ACKNOWLEDGEMENTS

The Authors would like to thank the participants for their honest completion of the questionnaires.

References

REFERENCES

Altekruse S.F., Yang S., Timbo B.B. and Ángulo F.J. 1999. A multi-state survey of consumer food-handling and foodconsumption practices. Am. J. Prev. Med. 16: 216.

Angelillo LF. , Foresta M.F, Scozzafava C. and Pavia M. 200 1 . Consumers and foodborne diseases: knowledge, attitudes, and reported behavior in one region of Italy. Int. J. Food Microbiol. 64: 161.

Ansari-Lari M., Soodbakhsh S. and Lakzadeh L. 2009. Knowledge, attitudes and practices of workers on food hygienic practices in meat processing plants in Fars, Iran. Food Control 21: 260.

Badrie N., Gobin A., Dookeran S. and Duncan R. 2006. Consumer awareness and perception to food safety hazards in Trinidad, West Indies. Food Control 17: 370.

Baranowski T1, Perry CL. and Parcel G.S. 2002. How individuals, environments, and health behaviour interact.

Social Cognitive Theory. In: "Health Behaviour and Practice" 3rd Ed. Glanz, K., Rimer B.K. and Lewis, F.M. (Ed). p. 165. Jossey-Bass, San Francisco, CA.

Barrie D. 1996. The provision of food and catering services in hospital. J. Hosp. Infect. 33: 13.

Brewer M.S. and Prestai C. J. 2007. Consumer attitudes toward food safety issues. Journal of Food Safety 22 (2): 67.

Buccheri C1, Casuccio ?., Giammanco S., Giammanco M., Guardia M.L. and Mammina C. 2007. Food safety in hospital: knowledge, attitudes and practices of nursing staff of two hospitals in Sicily, Italy. BMC Health Services Research 7: 45.

Chassy B.M. 2010. Food safety risks and consumer health. New Biotechnology. In press.

Derea H.E., Salem E., Fawzi M. and Azeem A. 2008. Safety of patients' meals in 2 hospitals in Alexandria, Egypt before and after tiaining food handlers. Eastern Mediterranean Health Journal 14: 4.

FAO & WHO. 2008. Assuring food safety and quality. Guidelines for strengthening national food control systems. Joint FAO /WHO publication.

Fein S.B., LLn C.T.J, and Levy A.S. L995. Foodborne illness: perceptions, experience and preventive behaviors in the United States. J. Food Protect. 58: 1405.

Haapala I. and Probart C. 2004. Food safety knowledge, perceptions, and behaviors among middle school students. J. Nutr. Educ. Behav. 36: 7L.

Jevsnik M., Hlebec V. and Raspor P. 2008. Consumers' awareness of food safety from shopping to eating. Food Control 19: 737.

Köferstein F. and Abdulssalam M. L 999. Food safety in the 2 L st century. Bulletin of the World Health Organization 77 (4): 347.

Lytle L. 1995. Nutrition education for school-age children. Journal of Nutrition Education 27: 298.

McCarthy M., Brennan M., Kelly A. L1, Ritson C, de Boer M. and Thompson N. 2007. Who is at risk and what do they know? Segmenting a population on their food safety knowledge. Food Quality and Preference 18 (2): 205.

Mead P.S. and Slutsker L. L 999. Food-related illness and death in the United States. Emerg Infect. Dis. 5: 607.

Ministry of Health (Turkey). 2006. Basic health statistics of Turkey 2004. Ministry of Health Publications, Ankara.

Osaili T.M, Obeidat B.A. , Abu Jamous D.O. and Bawadi H.A. 20LL. Food safety knowledge and practices among college female students in north of Jordan. Food Control 22: 269.

Özbilgen S. 20 LO. Food safety education makes the difference: food safety perceptions, knowledge, attitudes and practices among Turkish university students. Journal of Consumer Protection and Food Safety. In press.

Raspor P., Jevsnik M. and Hlebec V. 2006. Consumers' awareness of food safety from shopping to eating. In: "Nutrition and food safety". D. Banati (Ed.), p.l 12. Consortium International Congress on Food Safety, The Safe Consortium, Brussels.

Redmond E.C. and Griffith CJ. 2004. Consumer perceptions of food safety risk, control and responsibility. Appetite 43: 309.

Sammarco M.L., Ripabelli G. and Grasso G.M. 1997. Consumer attitude and awareness towards food-related hygienic hazards. Journal of Food Safety 17: 215.

Sanlier N. 2009. The knowledge and practices of food safety by young and adult consumers. Food Control 20: 538.

Sanlier N. 2010. Food safety knowledge and the safe food handling behaviours of female and male consumers. Pakistan Journal of Medical Sciences 26 (3): 653.

Sanlier N., Cömert M. and Durlu Ozkaya F. 2010. Hygiene perception conditions of hotel kitchen staff in Ankara, Turkey. Journal of Food Safety 30: 415.

Sanlier N. and Turkmen F. 2010. Perception of hygiene among staff working in food companies. Research Journal of Medical Sciences 4 (3): 231.

Schäfer E., Schäfer RB. and Bultena G.L. 1993. Safety of the United States food supply: consumer concerns and behaviour. J of Consumer Studies and Home Economics 17: 137.

Shiferaw B., Yang S., Cieslak P., Vugia D., Marcus R., Koehler J., Deneen V., Ángulo F. and The Foodnet Working Group. 2000. Prevalence of high-risk food consumption and food -handling practices among adults: a multistate survey, 1996- L997. J. Food Prot. 63: 1538.

StinsonT.F, Gosh K., Kinsey J. and Degeneffe D. 2008. Do household attitudes about food defense and food safety change following highly visible national food recalls? Am. J. of Agri. Econ. 90: 1272.

Subba Rao G.M., Sudershan R.V, Rao P., Rao M.V.V. and Polasa K. 2007. Food safety knowledge, attitudes and practices of mothers: findings from focus group studies in South India. Appetite 49: 441.

Unusan N. 2007. Consumer food safety knowledge and practices in the home in Turkey. Food Control 18: 45.

Velusamy V., Arshak K., Koros tynska O., Oliwa K and Adley C. 2010. An overview of foodborne pathogen detection: In the perspective of biosensors. Biotechnology Advances 28: 232.

Walker E., Pritchard C. and Forsythe S. 2003. Food handlers' hygiene knowledge in small food businesses. Food Control 14: 339.

WHO. 1997. Unpublished data. Advisory Committee on Health Research. A research policy agenda for science and technology. World Health Organization, Geneva.

WHO. 1998. Unpublished data. Health education in food safety. World Health Organization, Geneva.

WHO. 2000. Foodborne disease: A focus for health education. World Health Organization, Geneva.

WHO. 2004. Surveillance programme for control of foodborne infections and toxications in Europe, 8th report, 1999-2000. Country reports: Turkey.

WHO. 2005. http://www.who.int/mediacentre/factsheets/ fs237/en/.

WHO. 2007. http://www.who.int/whr/2007/en/index.html Wilcocky M., Pun J. Khanonax and Aung M. 2004. Consumer attitudes, knowledge and behaviour: A review of food safety issues. Trends in Food Science and Technology 15:56.

Yarrow L, Renting V.M. and Higging M. M. 2009. Food safety education intervention positively influences college students' food safety attitudes, beliefs, knowledge, and selfreported practices. J. of Environ. Health 71: 30.

Paper received March 30, 2011 Accepted IuIy 19, 2011