An epidemiological study on the predictors of health status of food handlers in food establishments of teaching hospitals of North India.

INTRODUCTION: The US Centers for Disease Control and Prevention (USDHHS-CDC 1996) revealed that the outbreaks of food borne diseases include inadequate cooking, heating, or re-heating of foods consumption of food from unsafe sources, cooling food inappropriately and allowing too much of a time lapse. As we all know that the food handlers have been working in various types of community kitchen and their health status can affect the status of food hygiene which can lead to contamination of foods attributing to acute gastroenteritis and food poisoning in various subgroups of the population e.g., medical/dental/nursing students. The background characteristics of these food handlers may have important role to affect health status of these handlers.
METHODS: The indexed study was carried out among the food handlers working in the food establishments the 5 teaching hospitals of Bareilly city in U.P. India during one year i.e., from August 2013 to July 2014. The survey method using schedule was conducted to get information about the background characteristics and food handlers and each food handler was examined clinically for assessing health status. Chi-Square test was used as test of significance and regression analysis was also done to nullifying the effect of confounders.
RESULTS: The health status of the mess workers was found to be significantly associated with use of gloves, hand washing after toilet and hand washing before cooking and serving food.
CONCLUSION: The rationale of this study was that though many studies have been carried out to show the health status of the food handlers and their background characteristics, no study has highlighted the association of these background characteristics and personal hygiene practices with the health status of food handlers.

INTRODUCTION

As stated by WHO, each year over two million people die from diarrheal diseases, many of which are acquired from eating contaminated food from food service. Food borne diseases remain responsible for high levels of morbidity and mortality in the general population.[1] The most frequently reported food worker's errors were handling of food by a person either actively infected carrying a pathogen, bare-hand contact with food, failure to wash hands properly. Whenever necessary and insufficient cleaning of processing or preparation equipment orkitchen tools. Such unhygienic practise would cause contamination of the food and cross-contamination of Ready-to-eat (RTE) foods.[23]

Food businesses have become widespread in recent times, in response to the changing lifestyle and food consumption of people. They offer convenience and ease to access food to busy individuals, who are unable to pre- pare their own meals regularly at home. In large scale cooking, food passes through many hands, thereby increasing the chances of food contamination due to improper handling. Deliberate or accidental contamination of food during large production might endanger the health of consumers, and have very expensive repercussions on a country, as such outbreaks feature prominently in national statistics.[45]

There was general agreement revealed from several authors as good levels of knowledge towards food safety among food handlers and the effective practices of such knowledge in food handling were imperative in ensuring the safe production of food in any catering operations.[6] Recently, many studies pinpoint the need for training and education of food handlers in public hygiene measures due to their lack of knowledge on microbiological food hazards, temperature ranges of refrigerators, cross contamination and personal hygiene.[7] Education on food safety should be given to all staff in food processing businesses so as to bring behavioral changes besides adoption of positive attitudes.[8] Assessment of impact of food safety measures require reliable epidemiological estimates while no precise and consistent data exists regarding burden of food borne illnesses.

MATERIALS AND METHODS

A descriptive type of cross-sectional study was carried out during one year i.e. from August 2013 to July 2014 by purposefully selecting all the food handlers/mess-workers/canteens-workers worked any period of time during above said one year duration in all the 18 food establishments (messes and canteens) run/managed by the same management running/managing all the five important teaching hospitals in the Bareilly District of Uttar Pradesh. On an average these 18 foods establishments have been serving eatables to approximately 2399 medical students in the campuses of five teaching hospitals in the Bareilly city of Uttar Pradesh. The survey was carried out by of four researchers conducted several visits till all handlers worked during study period covered.

The tool of the study was a research schedule which was used to evaluate the knowledge and practices of food handlers about their personal hygiene and sanitary measures adopted in food establishments. It also included the questions assessing the health status of food handlers and preventive measures used by them in last 3 months. The history was restricted to 3 months for the purpose of better recall. The schedule has been designed to obtain information about the demographic characteristics e.g., age, sex, education, caste/category, below poverty line or above poverty line. The cut off for BPL for Rural and Urban areas was taken as Rs. 816 and Rs. 999 per capita per month respectively as given by Planning Commission of India (PCI) for twelfth Five Year Plan (2012-17).[9] By using schedule we also got information about occupational characteristics of food handlers e.g. job type, job duration and training taken etc. During survey the health status of food handlers was assessed for communicable diseases especially food borne infections e.g. acute diarrheal disease and systemic disorders e.g., hypertension, coma and diabetes mellitus. We also assessed whether the food handlers were vaccinated or given chemoprophylaxis against important communicable diseases like typhoid, tetanus and worm infestations during last three months. Data was analyzed using MS-Excel 2010,[10] and SPSS 12.0.[11] Chi-Square test was used as test of significance and regression analysis was done thereafter to know the independent association of the predictors of health status of food handlers. The “P” value less than 0.05 was considered as significant.

RESULTS

The health status of mess workers with respect to caste did not show significant association [Table 1]. The educational and occupational status also did not show significant association while there was significant association of the rural and urban background with the health status [Tables 2–4]. It has been clearly depicted in Table 4 that 78.3% of the mess workers who were diseased, belonged to urban background while only 21.7% of those from rural background found to be diseased. Also, there was no significant relationship of the health status with socio-economic status i.e. APL or BPL [Table 4]. Besides this, the duration of job and the training done had no significant effect on health status [Figure 1 and Table 5].

Table 1

Association of health status of mess workers with educational status

Table 2

Association of health status of mess workers with occupational status

Table 4

Association of health status of mess workers with poverty line

Figure 1

Association of health status of mess workers with duration of job. Chi-square value = 1.049, df = 3,P value = 0.789

Table 5

Association of health status of mess workers with training done

As far as the immunization and deworming of health workers is concerned, there was no significant effect of it on their health status [Tables 6–8]. Though the personal hygiene had no significant relationship with the health status of mess workers but the use of glove had been found to be a useful measure in the prevention of diseases [Tables 9 and 10]. Similarly, the practice of nail cutting and hand washing after toilet had no significant association with the health status of the mess workers but the habit of hand washing before cooking or serving food had significant association with the health status of mess workers [Tables 11–13]. Religion and caste also had no significant association with health status of mess workers [Figures 2 and 3].

Table 6

Association of health status of mess workers with T.T.immunisation

Table 8

Association of health status of mess workers with use of de-worming tablets

Table 9

Association of health status of mess workers with personal hygeine

Table 10

Association of health status of mess workers with use of gloves

Table 11

Association of health status of mess workers with nail cutting habit

Table 13

Association of health status of mess workers with hand washing before cooking

Figure 2

Association of health status of mess workers with caste. Chi-square value = 2.63, df = 2, P value = 0.268

Figure 3

Association of health status of mess workers with religion. Chi-square value = 0.146, df = 1, P value = 0.702

On applying logistic regression, the health status of the mess workers was found to be significantly associated with use of glove, hand washing after toilet and hand washing before cooking and serving food. Though there was a significant association with rural and urban background on application of Chi-square but on nullifying the effect of other confounders by regression analysis, the result was not found to be significant. Conversely, the habit of washing hands after toilet showed no significant association on application of Chi-square but on applying logistic regression, there was a significant association present. There is an inverse association observed between caste, occupational status, anti-typhoid immunization, deworming, personal hygiene, use of gloves and hand-washing before cooking/serving. There is 0.035 times less chances of developing disease in health workers with the use of gloves. Also, there are less chances of disease among the health workers who wash their hand before cooking as compared to those who do not [Table 14].

Table 14

Predictors of health status of mess workers: A multivariate logistic regression analysis

DISCUSSION

In the present study, 87.29% food handlers were apparently healthy and 12.71% were unhealthy. Dental caries (6.6%), anaemia (2.2%), hypertension (1.1%), cough/cold (1.1%), scabies (0.6%) and fungal infection (0.6%) were the diseases that are attributed to their unhealthy conditions while working in the food establishment of various teaching hospitals included in this study. In this study with the help of Chi-square test and multinomial logistic regression analysis we had analysed any association of certain demographic characteristics and personal hygiene practices for their unhealthy status during being in work infood establishment. After analysis it was observed that the only background characteristic i.e. residence of food handlers was significantly associated with the unhealthy conditions of food handlers in this study as it was observed that food handlers who were belonged to the urban background found to be unhealthier as compared with the food handlers of rural background when examined clinically during survey period in this study. Though there was a significant association with rural and urban background on application of Chi-square but independently on applying logistic regression, there was no such association found. Other background characteristics i.e. Age, gender, castes, educational status, occupational status were also not significantly found to be associated with their health status when analysed using same tests in this study.

On analysis of health status and preventive measures i.e., immunization and anti-worm medication no significant association was found.

The health status of the mess workers was found to be significantly associated with use of glove, hand washing after toilet and hand washing before cooking and serving food. Though the habit of washing hands after toilet showed no significant association on application of Chi-square but on applying logistic regression, there was a significant association present.

In one of the similar study,[12] the authors had revealed that majority (62.74%) of food handlers were apparently healthy in their study but 23.52% had injuries, 19.60% had fever and hypertension, 10% had anaemia, diabetes and poor nutritional status. In their study, again majority (68.09%) of food handlers reported some illness in the previous 3 months. Another study[13] observed that only 25.33% of food handlers suffered from one or more disease in the past 6 months. This observation was more close to our study as only small proportion of food handlers were had disease attributing to their unhealthy status.

To compare the findings of our study, we had reviewed several studies,[12131415] carried out among food handlers in food establishments in various parts of the world. These studies have been conducted on the health status of the food handlers with their background characteristics but none has shown the association of these factors with it unlike the present Therefore this study is an attempt towards the analysis of such predictors of food handlers using regression analysis to nullify the effect of confounders.

CONCLUSION

On the basis of observations, analysis and discussion in this study it can be concluded here that only belonging or holding good socio-economic background characteristics cannot help food handlers to stay healthy. Good personal hygiene practices adopted by food handlers while working in food establishments of teaching hospitals were the important measures to stay healthy. In this study it was also revealed that preventive measures were of no much useful in retaining good health by food handlers as preventive measures i.e., anti-worm, anti-typhoid, tetanus vaccines can only prevent worm infestations, typhoid fever, tetanus only. It can be well concluded that use of gloves, washing of hand after toilet and before cooking and serving has significant role in maintaining good health status of food handlers and subsequently maintaining good health status of students i.e., medical/dental/nursing students served by them in these teaching hospitals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Table 3

Association of health status of mess workers with residence

Table 7

Association of health status of mess workers with anti-typhoid immunisation

Table 12

Association of health status of mess workers with hand washing after toilet