Evaluation of Food Hygiene Education

20 BRITISH FOOD JOURNAL 96,11

IntroductionThe provision of food hygiene education as a means ofimproving food handling standards has beenrecommended by many authors[1-14]. Significantattention was paid to these issues during the review offood legislation which led to the publication of the FoodSafety Act in 1990[15-19]. The Act enables regulations tobe made requiring mandatory food hygiene education ortraining for food handlers. A draft of regulations, whichare intended to be introduced in 1995, has indicated thatthe requirement will be for food handlers to be trained,instructed and supervised in food hygiene according tothe work they do, reflecting the content of the EuropeanDirective on the Hygiene of Foodstuffs[20,21].

There is, however, a lack of evidence of improved foodhygiene standards resulting directly from trainingprogrammes. A survey of hygiene standards found byenvironmental health officers, during routine inspectionsof food premises in England and Wales, identified poortraining standards in most premises where inspectorsconsidered the hygiene so bad that the foods handledmight present a risk to consumers[22]. Tebbutt[23]identified significant correlations between managementattitude to training, level of training, knowledge aboutfood hygiene and standard of food handling procedures infood premises. Kitcher[24] reported high risk practices infood premises with untrained staff and converse good

practices where hygiene training had been conducted. Itis not clear to what extent any of these links are causal. Apositive management attitude to training is likely to beaccompanied by effective hygiene management in thebusinesses concerned. A voluntary training scheme willperhaps reach only those who already have an interest infood hygiene and endeavour to behave appropriately, thusmissing sectors of the industry where there is littleinterest and where there may be bad practice. Theintroduction of compulsory courses may have advantagesin ensuring wider coverage of food handling personnel.As it is not clear whether or how food hygiene courses canlead to improvements in food hygiene standards, thisarticle reviews reported evaluations of the impact of foodhygiene courses in an attempt to identify the key featuresof successful training programmes.

Evaluations of Courses in the UKAlthough no training programme is complete without anevaluation of its effectiveness, there are relatively fewreported evaluations of the effectiveness of food hygieneeducation in the UK. Those which have been identified donot make the case convincingly for food hygieneeducation in its current form.

Worsfold[25] evaluated a six-hour training coursecollecting data at three stages. An initial pre-courseknowledge assessment was followed by a post-courseknowledge and attitudes survey. Six months later,retention of knowledge and reported modifications tofood handling practices were examined. The conclusionsindicated greater awareness of sources of food safetyinformation and that participants “seem to be” more ableto identify food safety hazards and risks.

An examination of the impact of another six-hour basiclevel course reported that prior educational and workexperience had more influence on knowledge levels infood industry personnel than participation in thecourses[26]. Evaluation of the same course in anotherlocation found that the course had little influence onknowledge levels as, in the sample population studied,knowledge levels were high before participation in foodhygiene education[27]. The course did result in positiveattitudinal effects among students, possibly byreinforcing their understanding of the need for suitablefood handling practices; however, no improvement inintended behaviour was identified. The study thereforeconcluded that the expectations of the food industry –improvement in food handling practices – were not beingmet by basic level food hygiene education and that theseneeds might be better accommodated by the introductionof training based in the workplace and by ensuring asuitable working environment which would encouragestaff to follow the correct procedures.

Monitoring and maintaining the quality of training iscritical as it is also possible that some inadequate trainingmay be worse than no training at all[28]. Food handlersmay retain previous misconceptions about hygiene or

Formal training programmes will be moreeffective if supported by practical reinforcementof hygiene messages.

Evaluation ofFood HygieneEducation

British Food Journal, Vol. 96 No. 11, 1994, pp. 20-25© MCB University Press Limited, 0007-070X

Denise M. Rennie

Received 15 July 1994Accepted 5 August 1994

21EVALUATION OF FOOD HYGIENE EDUCATION

even be given the wrong information. Even in well-presented and factually accurate courses participantsmay misunderstand the information offered.Consideration of the outcomes of advanced level coursesidentified overall improvements in knowledge but someuptake of erroneous information[29]. Course participantsdemonstrated and retained increased food hygieneknowledge over a three-month period. This improvementcontrasted with no significant change in knowledgelevels of a control group. There were some reportedimprovements in food handling practices associated withcourse attendance but many respondents indicated thatthey did not have the authority nor the budgetary controlnecessary to introduce desirable changes, particularlywhere there was a perceived need for improvements inphysical facilities.

Evaluations of Courses in Saudi Arabia andRomaniaTonge[30] reported the development and introduction offood hygiene courses for staff in the mess halls of amilitary city being built in Saudi Arabia. Effectivenesswas measured by considering the average results ofbacterial swabs and routine food hygiene inspectionscores attained before and after the introduction ofcourses. Both indicators tended to fluctuate but there wasa general trend to improvement which could be related tothe uptake of courses. Problems of penetration existeddue to the turnover of staff and companies involved incatering, and the variability in voluntary uptake ratesamongst the catering companies.

A Romanian study involved 45 food workers whoparticipated in a health education initiative whichaddressed food hygiene and nutrition[31]. The studyaimed to identify factors which might maximize theeffectiveness of the education by the application ofquestionnaires addressing hygiene knowledge andapproaches to food handling operations. A parallelassessment of hygiene standards in the three cateringunits concerned was instituted by microbial examinationof swabs from food handlers’ hands and pertinentworkplace areas. The authors concluded that standardswere much improved in the three test units as comparedto control outlets. Success of the training was attributedto incorporating the results of microbiological analysis ofon-site swabs, as an illustration of workplace efficiency,into the educational intervention, thus consolidating thetheory being presented.

Evaluations of Courses in the USAAmerican literature on the subject is more easilyidentified. This is perhaps because courses wereintroduced as early as 1938[32]. Also, there has been onenationally recognized, certified course available theresince the late 1970s. The Applied Food Sanitation courseoffered by the National Institute for the FoodserviceIndustry (NIFI) is designed to be taught in sessionstotalling 15 hours and is often used as a basis for

educational programmes leading to certification offoodservice managerial staff. The course is supported bya dedicated text book which includes self assessmentexercises for students[33]. The operation of courses andevaluation programmes are therefore of long standingand in some cases have been able to compare like withlike. Also, the normal practice of recording numericalscores of hygiene standards following routine inspectionof food premises facilitates comparison over a period.Many of the evaluation reports indicate the failure offormal courses to generate improvements in foodhandling practices. Bower and Davis[34] acknowledgedthat although tens of thousands of food hygiene courseshad been taught by enforcement agency staff over a 30year period, the outcomes could not be consideredeffective.

A review of the effectiveness of food service managertraining in the USA, covering the period from 1971 to1984, explored the range of techniques available forevaluation[35]. The systems described are measures ofthe incidence of food-borne illness; the frequencies ofinspectors finding foods stored at unsuitabletemperatures; inspection scores determined duringroutine visits; changes in knowledge levels of courseparticipants; and management attitude to enforcementagency staff. Three areas of the discussion are of interest:

(1) those managers thought to be most in need ofeducation were least likely to attend courses,especially if attendance was voluntary;

(2) the voluntary nature of courses evaluated resultedin sampling bias with respect to the standards inall food establishments;

(3) the studies which measured knowledge levels gavethe most reliable information but it was difficult toassess what effect these improved knowledgelevels actually had in the food industry.

The main recommendations[35] of the review are listedbelow:

(1) More information is needed to determine how foodhygiene education could be made more effective.

(2) National statistics on contraventions of foodhygiene legislation should be published andtechniques associated with the achievement ofgood standards investigated for wider application.

(3) The knowledge and skill requirements of thoseinvolved in maintenance of food hygiene standardsshould be established (i.e. the needs of managers,enforcers, teaching and training staff).

(4) National competency tests should be developed forall those involved in maintenance of food hygienestandards. (This recommendation was rejected bythe meeting at which the paper was presented).

(5) Distance learning or technological learningpackages should be developed for use bymanagers at times suitable to themselves.


(6) Training materials for managers to use withemployees should be developed and madeavailable.

(7) Information presented during training should bereinforced by enforcers during visits to premises.

The major issues of how food hygiene education can bemade more effective and promotion of systems associatedwith good hygiene standards are still of prime importancein the UK a decade later. Uncertainty about the factorsleading to a successful outcome from educationalinterventions inhibits the reliability of training as ameans to improve food industry hygiene standards. Asthe review concludes:

In order to change behaviour, individuals must be given theneeded knowledge; they must be motivated to use it; andtheir environment must permit the change to occur. Inaddition, enforcement and other activities must be used toreinforce what is taught in the training programmes[35].

The importance of motivation, reinforcement andsupport mechanisms are widely emphasized in generalhealth education literature[36-38] and are acknowledgedto varying extent in the food hygiene course evaluationsidentified for review.

Motivation and Reaction to CoursesIn an assessment of a NIFI course taught to food-servicemanagers involving 49 managers from 38 premises, itwas found that managers were more likely to enrol on thecourse if they believed the probability of contracting afood-borne illness was high; that the course was effectiveand that hygiene inspections of premises were relativelyineffective in improving hygiene standards[39]. The mainaim was to determine whether attendance and level ofsuccess on the course would be associated withimprovements in food premises’ hygiene standards. Dataavailable for comparison included the premisesinspection scores for six month periods immediatelybefore and immediately after the course and examinationmarks obtained by the managers taking the course.Eleven other factors which might have an influence oninspection score were also investigated[39]. These arelisted below:

(1) Whether premises were originally designed as arestaurant.

(2) Condition of equipment.(3) Number of full-time equivalent staff.(4) Total number of employees.(5) Percentage of employees who had taken local

sanitation courses.(6) Number of years business open.(7) Number of days open per week.(8) Number of hours open per week.(9) Number of people served daily.

(10) Number of seats.(11) Percentage of business carryout.

Only one of these – the condition of equipment – wasfound to have any significant influence on its own.Comparison of inspection scores of 22 of the participatingpremises with a control group of 35 did not find anysignificant difference in pre-course and post-courseinspection scores. No relationship was found betweenexamination marks and subsequent inspection scores.Two predictors of examination success were determined.These were the amount of homework done by thestudents and the length of their experience in the foodindustry. The report concluded that there may be a casefor studying the influence of specific elements within thecourse rather than the course as a whole and that thecourse itself may need modification in terms of durationand the applicability of the material presented to thepractical working environment.

Walker[32] stressed the importance of gathering goodbaseline data prior to the introduction of courses so thatpost-course comparisons can be made. Such data couldalso be useful in the design of courses ensuring that theproblem areas identified in practice are covered in thesyllabus and presentations. While the need for andpotential mechanisms of evaluation were recognized inthe article, behavioural changes determined could not beattributed to courses. Other known influences on foodhygiene standards such as inspections, publicity, changesin management and incentive awards are not easilymeasured and are often not accommodated in the designof course evaluations.

Mandatory or Voluntary CoursesResearch into the effectiveness of 26 food hygieneeducation programmes considered the length of time theprogrammes had been in operation; the course duration,structure, syllabus and reference materials; thequalifications of tutors; cost effectiveness; whetherattendance was mandatory or voluntary, and the resultsof any individual course evaluations[40]. Where courseswere compulsory, almost 90 per cent of managers werecertified and if attendance was voluntary, less than 30 percent certification existed. Improvement in food servicehealth inspection scores following courses was claimedby 91 per cent of enforcement agencies which hadmandatory training courses, compared with only one-third of those with voluntary courses. This suggestedthat mandatory courses were more effective. However,full responses to the evaluation questions were receivedfrom only nine of the respondents. Six voluntary andthree mandatory providers had identified improvementsin knowledge by the application of pre-course and post-course tests to participants.

Other writers have also identified mandatory courseattendance as beneficial[32,41,42]. A low uptake ofvoluntary courses in Minnesota led to the introduction ofa mandatory programme for managers of food serviceestablishments[41]. The courses aimed to reduce theincidence of food-borne illness. An interviewer visited 16premises by appointment, to interview the holder of the


food hygiene course certificate. A structured discussionwas used as the basis for the production of a knowledgeand practice score for the manager and premises. Thescore derived was then compared with previousinspection scores obtained from hygiene enforcementstaff. Positive correlations were found between the unitmanagers’ score and the general inspection score. Specificimprovements reported by enforcement staff in the twoyear period after certification had been made mandatorywere mainly procedural (time and temperature control offood, e.g. increased use of thermometers, more efficientcooling of food, thawing of frozen food under refrigeratedconditions; and cross contamination, e.g. the arrangementof raw and cooked foods in refrigerated storage). Thecourse also led to expansion in communications betweenthe enforcement agency staff and the managers involved.

The impact of voluntary training courses was reported inorder to convince legislators that introduction of amandatory programme would result in an improvementin the ways in which food premises operated[42]. A totalof 115 food service establishments were selected forstudy, representing approximately 10 per cent of theestablishments within an enforcement authority’sjurisdiction. Managers from 58 of the premises wereinvited to and agreed to attend a training programme.The remaining 57 premises were to act as a control group.In practice only 18 managers attended the course,demonstrating the difficulty in obtaining attendancewhen there is no legal requirement. Evaluation dataconsisted of pre-course and post-course inspectionresults; pre-course and post-course knowledgeassessments; and the information from questionnairesaddressing attitude towards the course and theenforcement agency. The questionnaire results showed animproved manager attitude to the enforcement agency.Although the managers reported an interest in trainingemployees this did not happen in practice and there wasno significant improvement in the knowledge of the 27managers who completed both pre-course and post-course tests. The study group’s premises were found to besignificantly poorer than the control group’s premises interms of equipment and structural requirements prior tothe course. In the three post-course inspections thissignificant difference no longer existed. The increasedfrequency of inspections during part of the study periodled to an improvement in standards in both course andcontrol groups. There was a longer interval between laterinspections and reduced standards were found.

Reinforcement of TrainingThe short- and long-term influences of managementtraining in a fast-food restaurant chain were assessed andreported in two stages[43,44]. Following an initialinspection to identify standards, the managers of 31 fastfood restaurants were provided with in-house hygienetraining. The training comprised two meetings each ofapproximately two hours duration to present theapplication of good hygiene practices and enable on-sitediscussion and encouragement. Case studies of premises

within the chain were used to illustrate ways ofimproving standards. Post-course surveys of therestaurants showed overall improvements in inspectionscores. This effect was attributed to the level of supportfor the courses and corrective action offered by the parentcompany. Two years after the initial pre-courseinspection, follow up visits were made to the restaurants.In 19 of the premises there was a different manager andthe inspection scores tended towards the pre-courseinspection levels. Where managers were still at the samesite, the improvement over pre-course inspection was notas marked as it had been at the previous post-courseinspection visit. This fall-off in standards suggested aneed for frequent reinforcement of the hygiene messageand continued support from management to train newemployees.

Burch and Sawyer[45] investigated the influence ofmanagers’ and staff hygiene knowledge on hygienestandards in 13 retail premises where high risk foodswere prepared. Four of the 13 managers and eight of the27 members of staff interviewed had received hygienetraining during their current employment. A further sixmembers of staff had previous experience of hygienetraining. The training reported was mainly informal andnone of the participants held a NIFI certificate. A shortknowledge test was applied. There were two openquestions, about the recommended minimum holdingtemperature for hot foods and the maximum temperaturefor cold foods, and six statements about food storage,personal hygiene and cleaning practices which had to bemarked as either true or false. Only 15 per cent ofmanagers and 10 per cent of other staff gave correctanswers to both of the temperature questions. For the trueor false questions managers had a total of 51 per centcorrect answers and staff a total of 48 per cent correct.Respondents were also asked to rank themselves in termsof food hygiene knowledge. Managers ranked themselvesas having average to excellent knowledge and other staffperceived their personal knowledge to be average toabove average. Hygiene standards in the retail premiseswere found to be significantly correlated with the actualknowledge of managers but not with perceivedknowledge. The researchers recommended theintroduction of compulsory hygiene educationreinforcement programmes for managers.

Knowledge into PracticeA report on the effects of a certificated course in Illinoisshowed encouraging improvements in food handlingpractices[46]. Sixty food service establishments wereincluded in the study which involved identifying the dateof entry of certified managers to the establishments;reviewing the routine inspection results during the threeprevious years to set a base level and then comparing theresults of inspection which followed. A variety of certifiedparticipants were selected from courses which had beenoffered at different times in order to minimize theinfluence of media attention on hygiene issues, e.g.


reporting of large food-poisoning outbreak orprosecutions of the operators of similar food businesses.

The results showed that post-course inspection scoreswere higher than those that would have been anticipatedfrom the trends in pre-course inspection scores.Procedural items (e.g. food storage practices) showed astatistically significant improvement which continued forup to 18 months. After this time there was no furtherimprovement again suggesting that follow up action inthe form of re-certification or refresher courses may benecessary. Similar levels of improvement were notidentified for rectification of structural faults. This wasperhaps because of the financial implications of suchchanges; their lesser influence on hygienic food quality, orcourse participants not having control over these matters.

Hinckley[47] described the expansion of food hygienecourses run by New York City Health Department.Education of food handlers had been introduced in 1943.Low attendance rates and high staff turnover in the foodindustry led to the introduction of a priority scheme in1973. Where premises were found on inspection to haveserious contraventions of the local health code, the personholding the operating licence for the business wasrequired to attend a food protection course operated bythe city’s health department. An initial pre-courseknowledge test was applied so that the scores could becompared with the post-course examination results butany improvements identified are not presented in thearticle. The effectiveness of education was also measuredby relating the numbers of staff attending courses to thenumbers of recorded food-poisoning cases. The dataprovided is very short-term and questionable due to thewell known problems of under-reporting of foodpoisoning incidents and the very low proportion ofinvestigations where a cause is clearly identified. Finallya survey of 100 restaurants was conducted severalmonths after the managers had attended courses. In allcases the extent of failure to meet necessary hygienestandards had been reduced.

Evidence of knowledge not being translated into practiceis identified in relation to a major outbreak of foodpoisoning in South Carolina[48]. During the nine monthsprior to the outbreak, food hygiene enforcement staff hadworked with the manager and employees of a restaurantrepeatedly to ensure they understood how to prepare foodsafely. As part of the sanctions introduced in an attemptto improve standards, the manager was required to takean examination on proper food handling practices. Sixmonths after he passed this test, food produced for aconvention gave rise to an outbreak of salmonellosis inwhich there were 135 known cases and an estimated 800persons affected.

ConclusionsAlthough many of the evaluations cited have not shownimprovements in food handling practices, theinvestigators almost invariably concluded that food

hygiene education programmes should be encouraged.The reasons for this anomalous recommendation wereusually concerned with the presentation of a good publicimage where an enforcement agency provided the coursesalong with an improvement in communications andrelationships between personnel in the food industry andin enforcement agencies. If such image and publicrelations improvements are the goals of food hygieneeducation then it can be perceived as successful. If,however, the goals are improvement in the hygienichandling of foodstuffs and a reduction in the incidence offood-borne disease, then formal educational programmesmight be an inappropriate strategy and resources may bebeing misdirected.

There is evidence that ongoing reinforcement of thehygiene messages in the workplace is essential if desiredfood handling practices are to be sustained. Improvementin food hygiene practices can also be fostered byprovision of a physical and social environment whichsupports the application of appropriate food handlingbehaviours. Training activities closely associated withsuch an environment would be more appropriate thanfood hygiene courses which operate in settings divorcedfrom the workplace and use solely knowledge-basedassessment techniques. Reliable work site evaluationtechniques should also be introduced taking account ofthe fact that knowledge alone does not lead to changes infood handling practices. Good baseline data will benecessary for comparative purposes. Process evaluationwill be necessary to shape the development of trainingprogrammes introduced to comply with the forthcomingregulations in the UK and elsewhere in the EuropeanUnion. Ongoing evaluations will be required to monitorthe effectiveness of the training provided and identify thefeatures of programmes associated with improvements inworkplace hygiene standards in particular circumstances.

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Denise M. Rennie is a Lecturer in the Environmental Health and Housing Department, University of Salford, Salford, UK.

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Evaluation of Food Hygiene Education