DEVELOPMENT OF INTERVENTIONS TO IMPROVE FOOD …

DEVELOPMENT OF INTERVENTIONS TO IMPROVE FOOD HANDLERS HAND WASHING PRACTICES IN SELECTED SCHOOL CANTEENS IN

THE KLANG VALLEY, MALAYSIA

IZZAH AZ ZAHRA BINTI AHMAD

FSTM 2019 23

DEVELOPMENT OF INTERVENTIONS TO IMPROVE FOOD HANDLERS

HAND WASHING PRACTICES IN SELECTED SCHOOL CANTEENS IN


By


Thesis Submitted to the School of Graduate Studies, Universiti Putra Malaysia,

in Fulfilment of the Requirements for the Degree of Master of Science

January 2019

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All material contained within the thesis, including without limitation text, logos,

icons, photographs and all other artwork, is copyright material of Universiti Putra

Malaysia unless otherwise stated. Use may be made of any material contained within

the thesis for non-commercial purposes from the copyright holder. Commercial use

of material may only be made with the express, prior, written permission of

Universiti Putra Malaysia

Copyright © Universiti Putra Malaysia

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Abstract of thesis presented to the Senate of Universiti Putra Malaysia in fulfilment

of the requirement for the degree of Master of Science

DEVELOPMENT OF INTERVENTIONS TO IMPROVE FOOD HANDLERS

HAND WASHING PRACTICES IN SELECTED SCHOOL CANTEENS IN


By


January 2019

Chairman: Ungku Fatimah Ungku Zainal Abidin, PhD

Faculty: Food Science and Technology

In Malaysia, most of the reported cases of food poisoning occurred in public school

canteen and because of that various efforts are made by Malaysian government to

improve food safety practice in school canteen. However, despite the efforts the

number of food poisoning cases still reported today. The food handlers in the

institutional foodservice such as public school canteen must follow the proper food

safety practice to prevent the outbreak of foodborne diseases. Addressing the hand

washing practices is one way to improve food safety practices. It has been reported

by prior studies that food handlers in Malaysia have low compliance rate of hand

washing practices. And, there are lack of intervention studies to improve food

handlers hand washing practices especially in Malaysia. Most of food safety

intervention studies more focused on knowledge, although there are many possible

factors beyond knowledge that affecting food safety practices. Therefore, the main

objectives in this study is to develop hand washing intervention based on factors that

affecting food handlers hand washing practices. Among others the objectives in this

study is to elicit the beliefs of hand washing practices among food handlers and to

identify specific factors that influence their hand washing practices. To achieve the

objectives, this study employed mixed-methods approach which involved phase one

and phase two. In the Phase One, a series of seven focus group discussions were held

with food handlers from school canteen to assess food handlers’ beliefs on the hand

washing practices at their workplace. The guide questions based on The Theory of

Planned Behavior was employed during focus group discussion and the themes

emerged were categorized according to the theory framework. Next, phase two

involved survey and development of intervention. Findings from focus group

discussion were used in survey instrument development. Then, a survey was

conducted with 83 food handlers from public school canteen. The PLS-SEM

analysed of survey revealed that only subjective norm significantly and positively

predicts the food handlers’ intention to perform proper hand washing practices based

on the path coefficient of 0.748 (p<.001). These suggests that food handlers’

subjective norms (e.g. manager, school administration, customer, co-worker, health

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officer) positively influence the food handlers hand washing practices. The

development of intervention was continued afterward by incorporated the subjective

norm factor and feedback performances was developed as main intervention with the

integration of poster reminder and installation of soap and paper towel dispensers.

The effectiveness of interventions was measured through the direct observation of

food handlers hand washing practices in control group and intervention group during

pre and post observation. The results of interventions do not significantly improve

the hand washing compliance rate of food handlers. This could be due to various

factors that affect interventions such as the way feedback performance were given,

habit of food handlers and absent or lack of food safety culture in food handlers’

workplace. Although the implemented interventions do not improved hand washing

compliance rate among food handlers, the finding still provides a valuable

information to the management of school canteen, school administration and public

authorities in their efforts to improved food safety practice in general and hand

washing practices.

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Abstrak tesis yang dikemukakan kepada Senat Universiti Putra Malaysia sebagai

memenuhi keperluan untuk ijazah Master Sains

PEMBANGUNAN INTERVENSI BAGI MENINGKATKAN AMALAN-

AMALAN MENCUCI TANGAN PENGENDALI MAKANAN DI KANTIN-

KANTIN SEKOLAH TERPILIH DI LEMBAH KLANG, MALAYSIA

Oleh


Januari 2019

Pengerusi: Ungku Fatimah Ungku Zainal Abidin, PhD

Fakulti: Sains dan Teknologi Makanan

Di Malaysia, kebanyakan laporan kes keracunan makanan berlaku di kantin sekolah

awam dan oleh kerana itu pelbagai usaha dilaksanakan oleh kerajaan Malaysia untuk

meningkatkan amalan keselamatan makanan di kantin sekolah. Namun begitu kes

keracunan makanan masih banyak dilaporkan sehingga hari ini. Pengendali makanan

yang bekerja didalam institusi perkhidmatan makanan seperti kantin sekolah awam

mesti mengikut amalan keselamatan makanan yang betul untuk mencegah penyakit

wabak makanan. Menekankan amalan mencuci tangan dengan betul adalah salah satu

cara untuk meningkatkan amalan keselamatan makanan. Kajian terdahulu

melaporkan bahawa pengendali makanan di Malaysia mempunyai kadar pematuhan

yang rendah terhadap amalan mencuci tangan. Dan terdapat juga kekurangan kajian

intervensi bagi memperbaiki amalan mencuci tangan oleh pengendali makanan

terutamanya di Malaysia. Kebanyakan kajian intervensi bagi keselamatan makanan

lebih tertumpu kepada pengetahuan, walaupun terdapat banyak faktor selain

pengetahuan yang boleh mempengaruhi amalan keselamatan makanan. Oleh itu,

matlamat utama dalam kajian ini adalah membangunkan intervensi terhadap amalan

mencuci tangan berdasarkan faktor-faktor yang mempengaruhi amalan mencuci

tangan pengendali makanan. Selain itu, objektif lain dalam kajian ini adalah untuk

mendapatkan kepercayaan amalan mencuci tangan di kalangan pengendali makanan

dan mengenal pasti faktor-faktor tertentu yang mempengaruhi amalan mencuci

tangan mereka. Bagi mencapai objektif berikut, kajian ini menggunakan kaedah

pendekatan campuran berturutan yang melibatkan fasa pertama dan fasa kedua.

Dalam fasa pertama tujuh siri perbincangan kumpulan fokus telah diadakan dengan

pengendali makanan dari kantin sekolah untuk menilai kepercayaan mereka terhadap

amalan mencuci tangan di tempat kerja. Soalan panduan berdasarkan Teori Panduan

Perilaku Tingkah Laku Yang Dirancang telah digunakan semasa perbincangan

kumpulan fokus dan tema yang muncul daripada kumpulan fokus dikategorikan

mengikut kerangka teori (Teori Panduan Perilaku Tingkah Laku Yang Dirancang).

Seterusnya, fasa kedua melibatkan kajian soal selidik dan pembangunan intervensi.

Penemuan daripada perbincangan kumpulan fokus digunakan bagi pembangunan

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instrument kajian soal selidik. Kemudian, kajian soal selidik dijalankan dengan 83

pengendali makanan dari kantin sekolah awam. Perisian PLS-SEM yang digunakan

untuk menganalisa kajian soal selidik mendedahkan hanya norma subjektif yang

signifikan dan positif dalam meramalkan niat pengendali makanan untuk

melaksanakan amalan mencuci tangan yang betul (0.748 (p <.001)). Ini menunjukkan

bahawa norma subjektif untuk pengendali makanan (Pengurus, pentadbiran sekolah,

pelanggan, rakan sekerja, pegawai kesihatan) secara positif mempengaruhi amalan

pencuci tangan pengendali makanan. Seterusnya, intervensi dibangunkan dengan

memasukkan faktor norma subjektif dan laporan prestasi maklum balas digunakan

sebagai intervensi utama dengan mengabungkan poster peringatan dan memasang

sabun dan tisu kertas dispenser. Keberkesanan intervensi diukur melalui pemerhatian

secara langsung amalan mencuci tangan oleh pengendali makanan dalam kumpulan

kawalan dan kumpulan intervensi sebelum dan selepas pemerhatian. Keputusan

daripada intervensi tidak dapat meningkatkan pematuhan amalan mencuci tangan

pengendali makanan secara signifikan. Perkara ini mungkin disebabkan oleh

pelbagai faktor yang memberi kesan kepada intervensi sebagai contoh cara memberi

maklumbalas, kebiasaan pengendali makanan dan tiada budaya keselamatan

makanan di tempat kerja pengendali makanan. Walaupun intervensi yang

dilaksanakan tidak meningkatkan kadar pematuhan mencuci tangan di kalangan

pengendali makanan, hasil kajian memberikan keputusan yang berharga kepada

pengurusan kantin sekolah, pentadbiran sekolah dan pihak berkuasa awam dalam

usaha untuk meningkatkan amalan keselamatan makanan secara keseluruhandan

amalan mencuci tangan secara khusus.

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ACKNOWLEDGEMENTS

In the name of Allah, Most Gracious, Most Merciful. May the blessing of Allah fill

all the life of people surround me with happiness and peace in this world and in the

afterlife.

First, I would like to express my immense gratitude to my families for their love,

support, encouragement and prayer throughout the research and writing of this

master thesis. For my mother, my ummi and kak yah, thank you so much for all the

love that you all have showered on me. May Allah SWT have mercy upon them and

grant them all the highest ranks of Jannah. To my Abah (Ahmad bin Abdul Rahman),

may Allah SWT bless you with a good health and abundance of happiness in this

dunya and akhirah. I am very fortunate and grateful to my sisters and brothers for

their prayer and support. May Allah SWT bless all of you with good health,

prosperity and endless happiness in this dunia and akhirah. To my wonderful nieces

and nephew, please stay healthy, cute and happy!

Next, I would like to express the deepest appreciation to the people who have

supported and helped me throughout this learning journey. First and foremost, I owe

my deepest gratitude to my supervisor, Dr Ungku Fatimah Ungku Zainal Abidin. Her

valuable guidance, advice, continuous support and consideration helped me in all

time of research and writing of this thesis. As supervisor, she has taught me

incredible lesson as researcher and person. I am highly indebted to her. Besides, I

give deep thanks to the members of my supervisory committee, Dr Nor Ainy and Dr

Noor Khaizura for all of their advice and insightful comment I am extremely grateful

to have all of them as my mentors during this learning journey. Last but not least,

special and heartfelt thanks to all my friends for their constant love and support.

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This thesis was submitted to the Senate of Universiti Putra Malaysia and has been

accepted as fulfilment of the requirement for the degree of Master of Science. The

members of the Supervisory Committee were as follows:

Ungku Fatimah Ungku Zainal Abidin, PhD

Senior Lecturer

Faculty of Food Science and Technology


(Chairman)

Nor Ainy Mahyudin, PhD

Associate Professor



(Member)

Khaizura Mahmud @ Ab Rashid, PhD

Senior Lecturer



(Member)

______________________________

ROBIAH BINTI YUNUS, PhD

Professor and Dean

School of Graduate Studies


Date:

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Declaration by graduate student

I hereby confirm that:

• this thesis is my original work;

• quotations, illustrations and citations have been duly referenced;

• this thesis has not been submitted previously or concurrently for any other

degree at any other institutions;

• intellectual property from the thesis and copyright of thesis are fully-owned by

Universiti Putra Malaysia, as according to the Universiti Putra Malaysia

(Research) Rules 2012;

• written permission must be obtained from supervisor and the office of Deputy

Vice-Chancellor (Research and Innovation) before thesis is published (in the

form of written, printed or in electronic form) including books, journals,

modules, proceedings, popular writings, seminar papers, manuscripts, posters,

reports, lecture notes, learning modules or any other materials as stated in the

Universiti Putra Malaysia (Research) Rules 2012;

• there is no plagiarism or data falsification/fabrication in the thesis, and scholarly

integrity is upheld as according to the Universiti Putra Malaysia (Graduate

Studies) Rules 2003 (Revision 2012-2013) and the Universiti Putra Malaysia

(Research) Rules 2012. The thesis has undergone plagiarism detection software.

Signature: ________________________ Date: __________________

Name and Matric No.: Izzah Az Zahra Ahmad (GS41526)

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Declaration by Members of Supervisory Committee

This is to confirm that:

• the research conducted and the writing of this thesis was under our supervision;

• supervision responsibilities as stated in the Universiti Putra Malaysia (Graduate

Studies) Rules 2003 (Revision 2012-2013) are adhered to.

Signature:

Name of Chairman of

Supervisory

Committee:

Ungku Fatimah Ungku Zainal Abidin

Signature:

Name of Member of

Supervisory

Committee:

Nor Ainy Mahyudin, PhD

Signature:

Name of Member of

Supervisory

Committee:

Noor Khaizura Mahmud @ Ab Rashid, PhD

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TABLE OF CONTENTS

Page

ABSTRACT i

ABSTRAK iii

ACKNOWLEDGEMENTS v

APPROVAL vi

DECLARATION viii

LIST OF TABLES xiv LIST OF FIGURES xv LIST OF ABBREVIATIONS xvi

CHAPTER

1 INTRODUCTION 1 1.1 Introduction 1 1.2 Background of Study 1

1.3 Problem Statement 4 1.4 Research Objectives 5 1.5 Significance of Study 5

1.6 Thesis Organization 5

2 LITERATURE REVIEW 7 2.1 Introduction 7

2.2 Foodservice Operations 7

2.2.1 Food safety in foodservice operations 9 2.2.2 Hand hygiene practice and hand washing practices

in foodservice operations 10

2.3 Factors that Influence Food Safety Practices in Foodservice

Industry 11 2.3.1 Food handlers’ characteristics 15 2.3.2 Food handlers’ knowledge 15 2.3.3 Attitude, beliefs, and motivation 16 2.3.4 Environment (infrastructure and resources) 17

2.3.5 Management 17 2.3.6 Policies and enforcement (at local, state, and federal levels) 18 2.3.7 Social norms 18

2.4 Factors that Influence Hand Washing Practices in

Foodservice Industry 19 2.4.1 Knowledge 19 2.4.2 Attitude, beliefs, and motivation 22

2.4.3 Environment (infrastructure and resources) 22 2.4.4 Management 23 2.4.5 Policies and enforcement 23 2.4.6 Social norms 23

2.5 Interventions for Improved Food Safety Practices 24 2.5.1 Food safety interventions on knowledge, attitude, and

practices 24

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2.5.2 Food safety interventions on behavior 27

2.6 Interventions for Improved Hand Washing Practices 27 2.7 Key Theories as Underlying Basis for Studies on Hand

Washing Practices 28

2.7.1 Theory of planned behavior (TPB) 29 Behavioral beliefs and attitude 30 Normative beliefs and subjective norms 30 Control beliefs and perceived behavioral control 30 Intention 31

The application of TPB in studies on food safety 31 2.7.2 Other social cognition models 32

Health belief model (HBM) 32 Health action process approach (HAPA) 32 The transtheoretical model (stages of change) 33

3 METHODOLOGY 34 3.1 Introduction 34 3.2 Research Design 34 3.3 Research Sample 35

3.4 Phase One 36 3.4.1 Focus group sample 37

3.4.2 Development of guiding questions for focus group

discussion 37 3.4.3 Data collection 38

3.4.4 Data coding and analysis 38 3.5 Phase Two 40

3.5.1 Questionnaire survey instrument 40 Generation of questionnaire survey items 40

Development of questionnaire constructs and

items 40

Sampling strategy 42

Distribution of questionnaire surveys 43 Data analysis 43

3.5.2 Development of hand washing intervention 44 Sample 45 Data collection (pre-observation and

post-observation) 45 Data analysis 47

4 RESULTS AND DISCUSSION 48 4.1 Introduction 48 4.2 Phase One: Results and Discussion 49

4.2.1 Demographic profile of focus group participants 49 4.2.2 Focus group discussion (themes) 51

Behavioral beliefs (Advantages and

disadvantages) 52 Control beliefs (Facilitators and barriers) 55 Normative beliefs 59

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4.3 Phase Two: Results and Discussion 61

4.3.1 Data screening 61 4.3.2 Demographic profile of participants in questionnaire survey 61 4.3.3 Analysis of questionnaire survey responses 63

Measurement model 64 Structural model 66

4.3.4 Questionnaire survey discussion 68 4.3.5 Demographic profile of intervention participants 71

The compliance rate of hand washing practices 73

The comparison between control group

and intervention group in pre-test and post-test 76 The compliance rate of seven-step procedure

of hand washing practices 76 4.3.6 The impact of intervention on hand washing practices

among food handlers 77 4.4 Chapter Summary 80

5 SUMMARY, CONCLUSION AND RECOMMENDATIONS

FOR FUTURE RESEARCH 81

5.1 Introduction 81 5.2 Summary of Findings 81

5.2.1 Objective 1: To elicit the beliefs on the hand washing

practices among food handlers at the school canteen 81 5.2.2 Objective 2: To identify the specific factors that influence

hand washing practices among food handlers 82 5.2.3 Objective 3: To develop the intervention to improve

hand washing practices among food handlers at the

school canteen 82

5.2.4 Objective 4: To evaluate the effectiveness of the

developed intervention on hand washing practices among

food handlers 82

5.3 Implications of Study 83 5.4 Limitations of Study and Recommendations for Future Research 84

5.5 Conclusion 86

REFERENCES 87 APPENDICES 101 BIODATA OF STUDENT 176

LIST OF PUBLICATIONS 177

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LIST OF TABLES

Table Page

2.1 Facilitators and barriers that influence food safety practices in the

foodservice operations

12

2.2 Facilitators and barriers that influence hand washing practices in

the foodservice operations

20

2.3 Food safety interventions on knowledge, attitude, practices, and

behavior

25

3.1 (a) The number of schools, student enrolment, and teachers in 2016 36

3.1 (b) The number of schools, student enrolment, and teachers in Klang

Valley between 2015 and 2016

36

3.2 Phases of thematic analysis 39

3.3 Items of salient beliefs with respect to hand washing practices 41

4.1 Intrepretation of Cohen’ Kappa 49

4.2 Demographic profile of focus group participants 50

4.3 Emerging themes from the focus group discussions 51

4.4 Demographic profile of respondents in the questionnaire survey 62

4.5 Assessment of the measurement model 65

4.6 Discriminant validity (intercorrelations) of constructs 66

4.7 Results of hypotheses testing 69

4.8 Demographic profile of intervention participants 72

4.9 Compliance rate of hand washing practices for control group and

intervention group

74

4.10 Comparison of pre observation and post-observation of hand

washing compliance rates for control group and intervention

group.

75

4.11 The comparison between control group and intervention in pre-test

and post-test.

76

4.12 Total number of food handlers who performed seven-step

procedure of hand washing practices in control group and

intervention group

77

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LIST OF FIGURES

Figure

Page

2.1 The Diversity of Foodservice Industry 8

2.2 Theory of Planned Behavior 30

3.1 Flowchart of Methodology 35

3.2 Local Municipalities in Greater Klang Valley 35

4.1 Intervention Process of Study 48

4.2 Research Model based on Theory of Planned Behavior 63

4.3 Structural Equation Model 67

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LIST OF ABBREVIATIONS

WHO World Health Organization

CDC Centers for Disease Control and Prevention

USD United States Dollar

MOH Ministry of Health

MOE Ministry of Education

DOSM Department of Statistics Malaysia

HACCP Hazard Analysis and Critical Control Points

HBM Health Belief Model

HAPA Health Action Process Approach

TPB Theory of Planned Behavior

TRA Theory of Reasoned Action

FDA US Food Drug and Administration

ECDC European Centre for Disease Prevention and Control

(ECDC)

EFSA European Food Safe Authority

NDSC National Disease Surveillance Centre

RTE Ready to Eat

FSQ Food Safety Quality

CAT Coding Analaysis Toolkit

IBM-SPSS International Business Machine - The Statistical Package for

the Social Sciences

PLS-SEM Path Least Square-Structural Equation Modeling

HOF Hand Washing Observation Form

AVE Average Variance Extracted

VIF The Variance Inflation Factor

HTMT Heterotrait-Monotrait Ratio of Correlations

ABIM Angkatan Belia Islam Malaysia

JAIN Jabatan Agama Islam Negeri

KEMAS Kemajuan Masyarakat

MARA The Majlis Amanah Rakyat

SMK Sekolah Menengah Kebangsaan

SKJC Sekolah Kebangsaan Jenis Cina

SKJT Sekolah Kebangsaan Jenis Tamil

SK Sekolah Kebangsaan

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CHAPTER 1

INTRODUCTION

1.1 Introduction

This chapter presents the background of study on the implications of foodborne

diseases in the institutional foodservice, the importance of hand washing practices,

and the interventions to improve hand washing practices in reducing the outbreak of

foodborne diseases. This chapter also describes the problem statement, the objectives

of this study and significance of study. Thesis organization is presented at the end of

this chapter.

1.2 Background of Study

The foodborne diseases are the results of ingesting contaminated food, which

adversely affect both health and economic aspects. A substantial number of the

population is diagnosed with foodborne diseases every year. The World Health

Organization (WHO) estimated that one in every 10 people in an estimated

population of 600 million experiences illness with 420,000 death cases due to the

foodborne diseases annually. The foodborne diseases affect children (under the age

of five years) the most with almost one-third (30%) of the total death cases (WHO,

2015). Besides that, the African region demonstrates the highest susceptibility

towards foodborne diseases, which is followed by the Southeast Asia region;

meanwhile, the American and European regions have the lowest susceptibility

towards foodborne diseases (WHO, 2015).

There are various economic implications of foodborne diseases, which include health

treatment cost and the cost of food industry loss. In the US alone, approximately

USD 7 billion are expended annually to manage the outbreak of foodborne diseases

in the foodservice industry, which involves lawsuit or legal fees, notifying the

consumers, food recall, and compensating for the related damages (Hussain &

Dawson, 2013). The cost of the outbreak of foodborne diseases outweighs the cost of

preventive and control measures for the foodservice industry (Bartsch et al., 2018).

Despite the substantial economic and health implications, the foodservice operations

are accountable for the majority of the outbreak cases of foodborne diseases globally.

For example, the Centers for Disease Control and Prevention [CDC] (2017), reported

that 467 outbreak cases of foodborne diseases occurred in the US were associated

with restaurants.

With that, all food producers and foodservice operators are responsible to ensure that

the prepared food is safe for public consumption. The institutional foodservice (i.e.,

school, hospital childcare, and community service), which typically serves a large

group of vulnerable people (e.g., children, patients, and elders), has greater

responsibility in the food preparation for safe consumption. Moreover, most of the

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cases of foodborne diseases in Malaysia occur in the education institutions. The

Ministry of Health (MOH) Malaysia reported 60 episodes of food positioning in

schools between 2015 and 2016 (April). In particular, 78.3% of the total episodes

occurred in the public schools and institutions under the Ministry of Education

(MOE) Malaysia, which increased from 30 cases in 2015 to 47 cases in 2016. There

are various ongoing efforts to address the outbreak of foodborne diseases, such as the

mandatory training for food handlers, the implementation of Guidebook for Safe

Food “(Buku Garis Panduan Makanan Selamat) and the enforcement of Food Act

1983 (Akta Makanan 1983), Food Regulations 1985 (Peraturan-Peraturan Makanan

1985), and Food Hygiene Regulations 2009 (Peraturan-peraturan Kebersihan

Makanan 2009) (Food Act 1983, 2016; MOE, 2019). Despite these various efforts,

the cases of food poisoning remain reported. For instance, three recent cases of food

poisoning, which involved 155 students from primary and secondary schools, were

reported in May, July, and August 2018 (Astro Awani, 2018; Bernama, 2018;

MyMetro, 2018).

Accordingly, the WHO (2006) identified five factors that contribute to the outbreak

of foodborne diseases, which included (1) inadequate cooking, (2) temperature

abuse, (3) contaminated utensils or equipment, (4) unsafe food sources, and (5) poor

personal hygiene. Meanwhile, prior studies identified poor personal hygiene as one

of the primary factors that contribute to foodborne diseases in the foodservice

industry (Chapman, Eversley, Fillion, Maclaurin, & Powell, 2010; Egan et al., 2007;

NDSC, 2004; Pellegrino, Crandall, O’Bryan, & Seo, 2015; Rajagopal & Strohbehn,

2013; Thaivalappil, Waddell, Greig, Meldrum, & Young, 2018; Yu, 2015).

Accordingly, the food handler in the foodservice industry who is directly involved in

the food preparation plays a key role in preventing the outbreak of foodborne

diseases given the potential risk of being the main carrier in the transmission of

pathogens, toxins, or chemicals to the prepared food. Therefore, the food handler’s

personal hygiene, especially their hand hygiene practice, is significantly important in

the foodservice industry—any hand hygiene malpractices can be a source of

infection that leads to the outbreak of foodborne diseases (Smigic et al., 2016).

The hand washing practices is essentially part of the hand hygiene practice.

Basically, the hand washing practices refers to the act of washing hands with water

and regular soap or antibacterial soap (WHO, 2009b). The hand washing practices is

an essential practice in the foodservice industry because hands are the primary

pathway of transmitting pathogens, toxins, or chemicals to the prepared food.

Despite that, prior studies highlighted that most food handlers do not apply proper

hand washing practices (Allwood et al., 2004; Pellegrino, Crandall, O’Bryan, et al.,

2015; Pellegrino, Crandall, & Seo, 2015). Besides that, Pragle et al. (2007) revealed

that majority of food handlers (68%) did not wash their hands and there were also

several food handlers that did not properly wash the soap residue off their hands

before preparing food. Strohbehn et al. (2008) also revealed that the retail

foodservice, such as assisted living (33%), restaurant (7%), childcare, and school,

also demonstrated similar trend of low compliance rate of hand washing practices

among the food handlers. Similarly, majority of the food handlers (88%) in Malaysia

failed to describe the proper procedure of hand washing practices despite being the

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most familiar and widely recognized practice among these food handlers (Tan,

Cheng, Soon, Ghazali, & Mahyudin, 2013).

Most studies on food safety identified education through training, specifically the

dissemination of knowledge on food safety, as the key element to enhance the food

safety practices in the foodservice industry. Apart from attitude and behavior, studies

on improving the food safety practices in Malaysia also focused on the training

aspect (Siow & Sani, 2011; Lee et al., 2012; Aziz & Dahan, 2013; Saad et al., 2013;

Tan, Bakar, et al., 2013; Tan, Cheng, et al., 2013; Abdullah Sani & Siow, 2014;

Rosmawati et al., 2015; Siau, 2015; Nik Husain et al., 2016; Woh et al., 2016).

However, the findings on the effects of training on food safety remain inconclusive

despite substantially explored in prior studies. Clayton, Griffith, Price, and Peters

(2002) revealed that 95% of the total participants (N = 137), specifically the

foodservice employees, received training on food safety, but 63% admitted to not

practicing safe food handling procedure. Besides that, Soon et al. (2012) conducted a

meta-analysis on the effectiveness of training on food safety and intervention on

hand hygiene practice, which revealed that the knowledge score on hand hygiene

practice increased following the completion of training, but the motivation to

practice good hand hygiene practice was not warranted. In other words, the

knowledge gained through training on food safety does not necessarily translate to

the actual practice (Arendt & Sneed, 2008), which was also supported by prior

studies (Green et al., 2007; Pragle et al., 2007). With respect to the factors that

influence the food handlers’ hand hygiene practice or hand washing practices, Green

et al. (2007) identified the type of activity at the workplace, the number and location

of sinks, and the availability of supplies and, Pragle et al., (2007), identified time

pressure and, inadequate facilities and supplies. Accordingly, both studies (Green et

al., 2007; Pragle et al., 2007) propounded the need for multidimensional or multiple-

components intervention to address various factors that influence the food handlers’

hand hygiene practice to improve the overall food safety practice. In addition,

Mitchell et al. (2007) emphasized the need to address both individual and contextual

factors that influence food safety practice in order to effectively transform the food

handlers’ behavior.

With that, prior studies applied various social cognition models, such as health belief

model (HBM) (Clayton & Griffith, 2008) and health action process approach

(HAPA) (Reyes, Lippke, Knoll, Blanca Moya, & Schwarzer, 2015), to identify these

factors that influence the hand hygiene practice. Accordingly, there are also other

studies that applied the theory of planned behavior (TPB) as the underlying

theoretical framework to predict the intention of performing food safety practice

(Clayton, 2004; Roberts & Barrett, 2011; Bai et al., 2014; Mullan et al., 2015).

(York, Brannon, Shanklin, Roberts, Barrett, et al., 2009) revealed that the single

application of either the theory of planned behavior (TPB) intervention or training on

food safety improves the food handlers’ food safety practices, but a combined

strategy of both the theory of planned behavior (TPB) intervention and training was

found to be the most effective intervention to address the barriers and improve the

food handlers’ food safety practices (i.e., hand washing practices and the use of

thermometer). The study generally demonstrated the potential of the theory of

planned behavior (TPB) in the prediction and intervention of food safety practices.

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1.3 Problem Statement

The foodborne diseases are of major public health concern globally and Malaysia is

of no exception. The transmission of pathogens, toxins, or chemicals to the prepared

food can be drastically minimized when the food handlers apply proper food safety

practices, especially hand washing practices. Moreover, the foodservice industry,

especially the institutional foodservice, serves vulnerable people, such as children,

patients, and elders. It is essential that the food handlers in the institutional

foodservice perform proper hand washing practices prior to preparing food for these

individuals with weaker immune system. These food handlers are responsible to

ensure that the prepared food is safe for consumption, and their hand washing

practices plays a key role in preventing the outbreak of foodborne diseases.

The reported cases of food poisoning in Malaysia mostly occur in schools (of both

primary and secondary schools). Addressing that, the Malaysian government has

implemented various strategies to address the outbreak of food poisoning, such as

regular inspection of the school canteens and kitchens at boarding schools, the

implementation of mandatory training for food handlers, the introduction of

regulatory guidelines (e.g., Guidebook for Safe Food [Buku Garis Panduan Makanan

Selamat] and Self Examination Program [Program Pemeriksaan Sendiri KENDIRI],

and the enforcement of legislations and regulations (e.g., Food Act 1983 (Akta

Makanan 1983), Food Regulations 1985 (Peraturan-peraturan Makanan 1985), and

Food Hygiene Regulations 2009 (Peraturan-peraturan Kebersihan Makanan 2009))

(Food Act 1983, 2016; MOE, 2019). However, the cases of food poisoning in

schools remain reported, such as the recent case that involved 103 MARA students in

August 2018 (MyMetro, 2018). The hand washing practices is an integral aspect that

should be critically addressed to prevent such outbreak. Unfortunately, the food

handlers in Malaysia do not perform proper hand washing practices (Tan, Bakar, et

al., 2013; Tan, Cheng, et al., 2013).

Therefore, it is pivotal to address potential factors beyond the food safety

knowledge, such as environmental, motivational, personal, and social factors, in

order to prevent the outbreak of foodborne diseases and to induce proper hand

washing practices among food handlers. As highlighted in prior studies, solely

depending on food safety training does not effectively improve or sustain the food

handlers’ hand washing practices. This study expected to identify significant factors

that improve hand washing practices as the basis for strategic intervention

development. Furthermore, most studies on food safety in Malaysia focused on

knowledge, attitude, and behavior as well as the microbial assessment. To date,

studies on identification of multifaceted factors that influence food handlers’ hand

washing practices remain scarce.This suggests that there are even fewer interventions

that are developed based on the multifaceted factors that influence hand washing

practices, especially among food handlers at the school canteens in Malaysia.

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1.4 Research Objectives

This study generally aimed to develop an intervention to improve hand washing

practices among food handlers at the public school canteens in Malaysia. The

specific objectives of this study are presented in the following:

1) To elicit the beliefs on the hand washing practices among food handlers at the

school canteen;

2) To identify the specific factors that influence hand washing practices among food

handlers;

3) To develop the intervention to improve hand washing practices among food

handlers at the school canteen;

4) To evaluate the effectiveness of the developed intervention on hand washing

practices among food handlers.

1.5 Significance of Study

With respect to the objectives of this study, this study focused on the public school

canteens across three states in Malaysia. This study extended the existing knowledge

base on food safety within the Malaysian context. The identified factors that

influence hand washing practices in this study established the basis for the

development of an effective intervention to improve the hand washing practices

among food handlers at public school canteens in Malaysia. Besides that, this study

extended the research prospects of hand washing practices given the

multidimensionality of the identified factors in this study. Adding to that, the

findings of this study contributed to the development of future interventions for the

management of school canteen (especially for the canteen manager or canteen

owner), school administration, and the public health authorities. After all, the

management of the school canteen is legally responsible for the health and safety of

students by preparing food that are safe for consumption. Thus, it is imperative that

the canteen managers or canteen owners fully comprehend the challenges and factors

that influence the food safety practices among food handlers. The findings of this

study were also expected to assist the management of the school canteen in their

efforts to enhance their strategies to promote food safety practices. Moreover, this

study was also expected to facilitate the school administration in advancing their

inspection programs and other strategies to monitor the management of the school

canteen. In addition, this study also contributed significant findings for the

management of public health authorities in their efforts to improve their existing

programs, policies, and other regulations on food safety among food handlers at the

school canteens.

1.6 Thesis Organization

Overall, this thesis consists of five chapters, which is organized as follows:

Chapter One presented the background of this study on the outbreak of foodborne

diseases globally, including Malaysia. This chapter also described the problem

statement, which addressed the existing cases of food poisoning, low compliance rate

of hand washing practices among food handlers, and limited studies on the factors

that influence food safety practices, especially in Malaysia.

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Chapter Two reviews related literature on the definitions of foodservice industry

and food safety in the foodservice industry. This chapter also subsequently discusses

the hand hygiene practice and hand washing practices. Besides that, this chapter also

reviews various factors and interventions that influence food safety practice,

including hand washing practices. Additionally, this chapter also reviews the adopted

theories in prior studies on food safety.

Chapter Three describes the methodology of this study. This study specifically

employed a mixed-methods approach. This chapter proceeds to describe the two

phases of data collection in this study. This chapter also discusses how this study

analyzes the obtained data in Phase One and Phase Two.

Chapter Four discusses the obtained results of Phase One and Phase Two, namely

the results of focus group discussion and questionnaire survey, with respect to the

objectives of this study.

Chapter Five summarizes the major findings of this study. This chapter also

presents the limitations of study and recommendations for future research.

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