Food Control 18 (2007) 1180–1190www.elsevier.com/locate/foodcont

A review of food safety and food hygiene training studiesin the commercial sector

M.B. Egan a, M.M. Raats a,¤, S.M. Grubb a, A. Eves b,M.L. Lumbers b, M.S. Dean a, M.R. Adams c

a Food, Consumer Behaviour and Health Research Centre, University of Surrey, Guildford, Surrey GU2 7XH, UKb School of Management, University of Surrey, Guildford, Surrey GU2 7XH, UK

c School of Biomedical and Molecular Sciences, University of Surrey, Guildford, Surrey GU2 7XH, UK

Received 2 May 2005; received in revised form 2 August 2006; accepted 5 August 2006

Abstract

This review summarises the methods and results of studies conducted worldwide on the eVectiveness of food safety and food hygienetraining in the commercial sector of the food industry. In particular it focuses on those studies that have tried to evaluate the eVectivenessof such training. Forty-six studies of food hygiene training are included which used some outcome measure to assess the eVectiveness oftraining. The short-term nature and variety of measures used limited the majority of studies. The need for the development of evaluationcriteria of eVectiveness of food hygiene training is discussed.© 2006 Elsevier Ltd. All rights reserved.

Keywords: Food safety; Training; Evaluation; HACCP

1. Introduction

Food safety remains a critical issue with outbreaks offoodborne illness resulting in substantial costs to individu-als, the food industry and the economy (Kaferstein,Motarjemi, & Bettcher, 1997). Within England and Walesthe number of food poisoning notiWcations rose steadilyfrom approximately 15,000 cases in the early 1980s to apeak of over 60,000 cases in 1996 (Wheeler et al., 1999).This may be partly attributed to improved surveillance(GriYth, Mullan, & Price, 1995; Kaferstein & Abdussalam,1999) but may equally reXect increased global trade andtravel, changes in modern food production, the impact ofmodern lifestyles, changes in food consumption and theemergence of new pathogens (Collins, 1997; Tauxe, 1997).Recent years have seen a reversal in this trend but food poi-soning remains a high priority for the public and govern-ment (Parliamentary OYce of Science & Technology, 2003).

* Corresponding author. Fax: +44 1483 689553.E-mail address: m.raats@surrey.ac.uk (M.M. Raats).

0956-7135/$ - see front matter © 2006 Elsevier Ltd. All rights reserved.doi:10.1016/j.foodcont.2006.08.001

Mishandling of food plays a signiWcant role in the occur-rence of foodborne illness. Improper food handling may beimplicated in 97% of all foodborne illness associated withcatering outlets (Howes, McEwan, GriYths, & Harris,1996). In two studies of general outbreaks of infectiousintestinal disease (IID) in England and Wales the primarycauses were related to poor food-handling practices(Djuretic, Ryan, & Wall, 1996; Evans et al., 1998). Improperpractices responsible for microbial foodborne illnesses havebeen well documented (Bryan, 1988) and typically involvecross-contamination of raw and cooked foodstuVs, inade-quate cooking and storage at inappropriate temperatures.Food handlers may also be asymptomatic carriers of foodpoisoning organisms (Cruickshank, 1990).

Food handler training is seen as one strategy wherebyfood safety can be increased, oVering long-term beneWts tothe food industry (Smith, 1994). A postal survey of manu-facturing, retail and catering food businesses by Mortlock,Peters, and GriYth (2000) revealed that less than 10% hadfailed to provide some food hygiene training for staV. Lessencouraging was the fact that less than 20% of managers

M.B. Egan et al. / Food Control 18 (2007) 1180–1190 1181

were trained to supervisory level. This lack of training forfood managers may restrict their ability to assess risks intheir business and to assign appropriate hygiene trainingfor their staV.

The aim of this review is to analyse studies of foodhygiene training; in particular studies that have attemptedto evaluate the eVectiveness of training. The studies will beevaluated principally on the outcome measures used in eachstudy and their limitations for evaluating training eVective-ness discussed.

2. Background

2.1. Food hygiene legislation in the United Kingdom

New food hygiene legislation has applied throughout theUK from 1st January 2006. Regulation 852/2004 (EC) ofthe European Parliament and Council on the Hygiene ofFood StuVs now applies to all food businesses. The FoodHygiene (England) Regulations (2006); also come intoforce and separate but similar legislation will apply in Scot-land, Wales and Northern Ireland. Article 5 states that:Food businesses operators shall put into place, implementand maintain a permanent procedure based on the princi-ples of hazard analysis critical control points (HACCP).With regard to training Chapter XII states that food busi-ness operators are to ensure that: “food handlers are super-vised and instructed and/or trained in food hygiene matterscommensurate with their work activity; that those responsi-ble for the development and maintenance of the procedurereferred to in Article 5 (1) of the Regulation or for the oper-ation of the relevant guides have received adequate trainingin the application of HACCP principles, and compliancewith any requirement of national law concerning trainingprogrammes for persons working in certain food sectors”.Managers responsible for maintaining a food safety man-agement system will require adequate training to enablethem to carry out the statutory requirement. Accordingly anew set of food safety qualiWcations will be launched in2006 to help train managers and other staV in the essentialsof food safety management systems. Furthermore Article 7of Regulation (EC) 852/2004 on the hygiene of foodstuVsprovides for the development of national Guides to GoodHygiene Practice and the Application of HACCP principles(known as Good Practice Guides). These guides are beingdeveloped by individual food sectors, in consultation withinterested parties. Butchers’ shop licensing has been with-drawn across the UK from the end of 2005. Since 1stJanuary 2006, all retail butchers are subject to the new EChygiene regulations that apply to all other retail and cater-ing businesses.

2.2. Hazard analysis and critical control points (HACCP)

HACCP is an internationally recognised food safetyassurance system that concentrates prevention strategies onknown hazards; it focuses on process control, and the steps

within that, rather than structure and layout of premises(Kirby, 1994; Worsfold & GriYth, 1995). HACCP estab-lishes procedures whereby these hazards can be reduced oreliminated and requires documentation and veriWcation ofthese control procedures (Codex, 1997). Whilst HACCPhas been widely adopted by the food manufacturing indus-try and the larger companies in the hospitality and cateringsector, there have been concerns about implementation bysmaller businesses. Barriers to the implementation ofHACCP in small businesses have been identiWed whichinclude lack of expertise, absence of legal requirements,Wnancial constraints and attitudes (Ehiri, Morris, &McEwen, 1995; Taylor, 2001; Walker, Pritchard, & Forsy-the, 2003; WHO, 1999).

2.3. Training and evaluation of training eVectiveness

The Manpower Services Commission (1981) deWnedtraining as ‘a planned process to modify attitude or skillbehaviour through learning experience to achieve eVectiveperformance in an activity or range of activities’. Evalua-tion is integral to the cycle of training, providing feedbackon the eVectiveness of the methods used, checking theachievement of the objectives set by both the trainer andtrainee and in assessing whether the needs originally identi-Wed have been met (Bramley, 1996). Criteria that maybe used for evaluating the eVectiveness of a trainingprogramme include reaction to training, knowledge acqui-sition, changes in job-related behaviour and performanceand improvements in organisational-level results (Kirkpa-trick, 1967). Research on training eVectiveness has focusedprimarily on factors that are directly related to trainingcontent, design and implementation (Tannenbaum & Yuki,1992). However other factors outside the training environ-ment may inXuence the eVectiveness of any programme(Tracey, Tannenbaum, & Kavanagh, 1995).

Despite general acceptance that training eVorts must besystematically evaluated, few studies have tried to identifythe beneWts food hygiene training brings to the industry.This is illustrated by a survey of the US lodging industrywhere fewer than 10% of the hospitality companies con-ducted formal evaluations of their training programmes(Conrade, Woods, & Ninemeir, 1994).

2.4. Transfer of knowledge into practice

To be eVective food hygiene training needs to targetchanging those behaviours most likely to result in food-borne illness. Most food hygiene training courses relyheavily on the provision of information. There is animplied assumption that such training leads to changes inbehaviour, based on the Knowledge, Attitudes and Prac-tices (KAP) model. This model has been criticised for itslimitations (Ehiri, Morris, & McEwen, 1997b; GriYth,2000). It is accepted that knowledge alone is insuYcient totrigger preventive practices and that some mechanism isneeded to motivate action and generate positive attitudes

1182 M.B. Egan et al. / Food Control 18 (2007) 1180–1190

(Tones & Tilford, 1994). In an evaluation of food hygieneeducation Rennie (1994) concluded that knowledge alonedoes not result in changes in food handling practices. Vari-ous studies have shown that the eYcacy of training interms of changing behaviour and attitudes to food safety isquestionable (Mortlock, Peters, & GriYth, 1999).

3. Overview of studies

3.1. Mapping exercise

The aim of the review was to identify criteria used byprevious studies to evaluate the eVectiveness of food safetyand hygiene training. Reports referring to training in thecontext of food safety training or food hygiene training inthe commercial sector were considered relevant. Only thosestudies written in the English language were included.

DiVerent sources of published and unpublishedresearch literature were searched to locate relevant papers.Searches were conducted on commercially available elec-tronic databases including PsycINFO, Medline, ERIC,CINAHL, Social Science Citation Index, Science Direct,etc. These searches covered the full range of publicationyears available in each database at the time of searching.For all the databases the following search strategy wasused: [{Food safety} or {Food hygiene}] and [{train*} or{teach*} or {course*} or {educat*}]. All citations identi-Wed by these searches were downloaded and when possiblecaptured and compiled as a Reference Manager database.Further studies were identiWed through hand searchingjournals and references to publications in retrievedpapers.

3.2. General characteristics of relevant studies included in review

Studies were included in the review if they met twocriteria:

• The study used some outcome measures to assess theeVectiveness of food hygiene training.

• The study was based in a commercial setting.

A total of forty-six studies of food hygiene training wereretained and included in this review. Full details of theincluded studies are given in Tables 1–5. The earliest studyin this review was undertaken in 1969 and the most recentin 2003. Fifteen studies (32%) were from the UK, twenty(43%) from the USA, two (4%) each from Canada, Italyand Malaysia and one (2%) each from Australia, Bahrain,New Zealand, Nigeria and Saudi Arabia.

Thirty studies (65%) involved food handlers, 11 (24%)focused on food managers and one study involved both(Burch & Sawyer, 1991). The level of training was not spec-iWed in the majority of the studies, the UK studies generallyused standard basic food hygiene courses. Twenty-twostudies (48%) included a training intervention (Tables 1 and

3–5). Twenty-nine studies (63%) measured knowledge(Tables 1 and 3–5). Most studies addressed attitude, behav-iour and work practices concerning food safety and foodhygiene in some form, however the methods varied greatly.

Only four of the studies (Ehiri et al., 1997b; Laverack,1989; Reicks, Bosch, Herman, & Krinke, 1994; Tracey &Cardenas, 1996) make reference to a social cognition theo-retical model as a basis for their study.

3.3. Training interventions

Of the 22 studies involving a training intervention, 15were from North America, Wve from the UK and one fromBahrain. North American training included courses forfood handlers and food service managers. It also encom-passed diVerent types of training such as home study, work-shops and more formal courses. A number of those studiesalso compared the results of using diVerent methods ofdelivering training. Seventeen of the 22 studies used aknowledge measure to evaluate the eVectiveness of theintervention, most commonly a pre- and post-test.

3.4. Study design and theoretical models

Few of the reports speciWed their study design. For clar-ity we have attributed each to one of the Wve evaluationdesigns detailed by Ovretveit (1998). A brief description ofeach of the designs is given here:

(i) Descriptive: Evaluator observes and selects features ofthe intervention, which he or she describes. Twenty-six of the 46 studies reviewed fell into this category(Table 1).

(ii) Audit: Evaluator compares what the service does withwhat it should or was intended to do, according towritten standards or procedures. Three (Audit Com-mission, 1990; Holt & Henson, 2000; Morrison,CaYn, & Wallace, 1998) of the 46 reviewed fell intothis category (Table 2).

(iii) Before–after: Evaluator compares a group of partici-pants before and after an intervention. Seven of the46 studies reviewed fell into this category (Table 3).

(iv) Comparative-experimentalist: Evaluator compares theoutcomes of two groups undergoing diVerent inter-ventions. Five (Costello, Gaddis, Tamplin, & Morris,1997; Howes et al., 1996; Kirby & Gardiner, 1997;Nabali, Bryan, Ibrahim, & Atrash, 1986; Rinke,Brown, & McKinley, 1975) of the 46 studies reviewedfell into this category (Table 4).

(v) Randomised controlled experimental: Evaluator com-pares one group that receives an intervention withanother group that does not, but that is in all otherpossible respects the same. Five (Ehiri et al., 1997b;Reicks et al., 1994; SoneV, McGeachy, Davison,McCargar, & Therien, 1994; Waddell & Rinke, 1985;Wright & Feun, 1986) studies fell into this category(Table 5).

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Table 1Food hygiene training evaluation studies using a descriptive design

Study and year Country Participants (number) Training intervention Knowledge Attitude, behaviourand working practices

Al-Dagal (2003) Saudi Arabia Sanitarians (n D 82) None Questionnaire Self-reported practicesBurch and Sawyer (1991) USA Managers (n D 13) and

employees (n D 27) of 13convenience stores

None Sanitation quiz(8 questions)

Researcher survey

Angellilo et al. (2000) Italy Food handlers (nD 411) None Face-to-faceinterviewsusing structuredquestionnaire

Self-reported hygienepractices

Angellilo et al. (2001) Italy Food handlers (nD 290) inhospitals (n D 36)

None Questionnaire Questionnaire

Clayton et al. (2002) UK Food handlers (n D 137)from 52 food SMEs

None Not assessed Questionnaire,self-reported practices

Cook and Casey (1979) USA Food service managers NIFI course, over a5-week period

Written examination Comparison of post-coursesanitation inspection scores

Hart et al. (1996) USA Beef demonstrators (nD 93) National RestaurantAssociationSERVSAVEprogramme

Pre and post-trainingquestionnaires

Pre- and post-trainingquestionnaires

Hennum et al. (1983) USA Restaurants (nD 16) None Interview Interview and observationHine et al. (2003) USA Restaurant managers

(n D 500)None Not assessed Survey

Johnston et al. (1992) New Zealand Managers of foodservice outlets (n D 300)

None Not assessed Questionnaire

Little et al. (2002) UK Take-away restaurantsand sandwich bars

None Not assessed Microbiological study

Manning and Snider (1993) USA Food handlers (n D 64) None Questionnaire Questionnaire,observation checklist

McElroy and Cutter (2004) USA Participants (n D 1,448)in Statewide Food safetyCertiWcation program (SFSCP)

Food safetyworkshop(16hrs)

Not assessed Self-reported changes infood safety behavioursassessed by questionnaire

Oteri and Ekanem (1989) Nigeria Hospital food handlers(n D 161)

None Not assessed Structured interview,observation of somepractices

Powell et al. (1997) UK StaV in 30 food premises CIEH basic certiWcatein food hygiene

Basic food hygienecertiWcate examination

Frequency inspectionratings

Sumbingco et al. (1969) USA Food service employees(n D 11) of universityresidence halls

Programmed texts fortwo food service tasks

Oral test Quality of work assessed,time for doing tasksmeasured

Tebbutt (1986) UK Premises selling slicedcooked meats (n D 160)

None Not assessed Microbiological sampling,questionnaire on cleaningand disinfection

Tebbutt (1991) UK StaV in 89 restaurants None Multiple choicequestions

Premises assessed

Tebbutt (1992) UK StaV in 75 premises producinghigh-risk foods

None Multiple-choicequestions

Numerical scores forpremises based on 20variables

Toh and Birchenough (2000) Malaysia Food hawkers (n D 100)from 15 sites

None Structured on-siteinterview

Thirteen attitude itemsusing a Likert scale

Wade (1998) UK Hospitality managers (nD 27) None Not assessed Survey of hygienemanagement

Walker et al. (2003) UK Food handlers (n D 444),from 104 small food businesses

None Multiple-choicequestions

Not assessed

Worsfold (1993) UK Members of the Women’sRoyal VoluntaryService (n D 93)

Royal Society ofHealth Basic Foodhygiene course

Pre-coursequestionnaire

End-of-course evaluation

Worsfold and GriYth (2003) UK Small or medium sizedbusinesses handling high-riskfoods (n D 66)

None Not assessed Semi-structured interviewwith manager; observationof hygiene practices

Wyatt (1979) USA Managers or owners of foodmarkets (n D 219)

None Questionnaire Questionnaire on attitudes,opinions, experiences andpractices

Zain and Naing (2002) Malaysia Food handlers (n D 430) None Questionnaire Questionnaire evaluatingattitude and practice

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3.5. Outcome measures

One of the aims of the review was to identify criteria forevaluating the eVectiveness of food safety and hygiene

training. Evaluation of training is complex given the num-ber of variables that may inXuence the outcome, includingwho is being trained, the level of training, motivation andcultural dimensions. Unfortunately few of the studies were

Table 2Food hygiene training evaluation studies using an audit design

Study and year Country Participants (number) Trainingintervention

Knowledge Attitude, behaviourand working practices

Audit Commission (1990) UK Food premises(n D 5,000)

None Not assessed Survey of premises andworking practices

Holt and Henson (2000) UK Manufacturers ofready to eat meatproducts (n D 24)

None Not assessed Hygiene audit usingEFSIS protocol

Morrison et al. (1998) Australia Food serviceoperations (n D 19)

None Not assessed Survey checklist us forpractices observed andstandards measured

Table 3Food hygiene training evaluation studies using a before-after design

Study and year Country Participants (number) Training intervention Knowledge Attitude, behaviour and workingpractices

Cotterchioet al. (1998)

USA 3 groups of traineerestaurant managers(nD 96)

Food manager trainingand certiWcation programme

Not assessed Routine sanitary inspection scorescompared pre- and post-training

Kneller andBierma (1990)

USA Food service facilities(n > 400)

None Not assessed Review of pre- and post-certiWcation inspection scores

Laverack (1989) UK Food handlers IEHO Basic Food HygieneCourse

Pre- and post-trainingtests

Questionnaire pre and post-training

Medeiroset al. (1996)

USA Food safety educators(nD 45) and voluntarycooks (n D 136)

Safe food handling foroccasional cooks trainingprogramme

Pre- and post-coursetest of 55 questions

Self-declared behaviour checklistused at time of initial training

Palmeret al. (1975)

USA Food service managersin 31 takeout restaurants

Manager trainingprogramme (2 £ 2 h sessions)

Not assessed Before and after survey of premises,total demerit score awarded

Sparkmanet al. (1984)

USA Food service workers(nD 23)

Food service trainingmanual, 3 h training session

Pre- and post-test with21 multiple-choicequestions post-training

On-the job performance evaluationwith 30 observations

Tracey andCardenas (1996)

USA Dining services divisionof two private colleges(nD 76)

Two food-service safetytraining programmes

Pre- and post-trainingtests based on coursetraining materials

Pre-training motivation assessedby survey, reactions to trainingsurveyed immediatelypost-training

Table 4Food hygiene training evaluation studies using a comparative-experimentalist design

Study and year Country Participants (number) Training intervention Knowledge Attitude, behaviourand working practices

Costelloet al. (1997)

USA Employees of 6 quickservice restaurants (n D 43)

Two teaching methods—lectureformat or computerinteractive method

Questionnaire—25multiple-choicequestions; pre- andpost-training tests

Not assessed

Howeset al. (1996)

Canada Food handlers (n D 69) Home study food-handlercertiWcation course

Pre- and post-instructiontests using 50multiple-choicequestions

Pre-observation of 16 foodsafety practices; post-observation of two handwashing practices

Kirby andGardiner (1997)

UK StaV in 30 food premises CIEH basic certiWcate infood hygiene

Not assessed Pre- and post-traininghygieneaudit for each premise

Nabaliet al. (1986)

Bahrain Food service managersin 24 premises

Manager training programme(2 £ 2.5 days sessions)

Pre- and post-coursetest of 50 questions

Pre- and post-courseinspection surveysof premises

Rinkeet al. (1975)

USA Food productionpersonnel in universityresidence halls (n D 60)

Training program, presentedas live instruction or tapedinstruction

Pre- and post-trainingtesting

Not assessed

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similar enough to allow any direct comparisons. Data werecollected using a variety of research methods. Theseincluded self-completed questionnaires, face-to-face inter-views, premises inspections, observation and microbiologi-cal sampling. We identiWed four outcome measures thatcould be used to compare the studies: knowledge; attitudes,behaviour and work practices; retraining and duration ofeVects. Our evaluation is based on these measures.

4. Results

4.1. Knowledge

Assessment of knowledge featured in 29 (63%) of thestudies reviewed here (Tables 1 and 3–5). Questionnaireswere used as the principal measure of knowledge. Generallythese were of multiple-choice format with the number ofquestions varying from 8 (Tracey & Cardenas, 1996) to 55(Medeiros et al., 1996), but some (e.g. Wright & Feun, 1986)providing no detail. Few of the studies detailed the ques-tions used, referring only to the general topics covered.These included high-risk foods, foodborne pathogens,cross-contamination, personal hygiene, temperature con-trol and cleaning. A number of the studies (Costello et al.,1997; Hart, Kendall, Smith, & Taylor, 1996; Laverack,1989; Medeiros et al., 1996; Nabali et al., 1986; Reicks et al.,1994; Taylor, 1996; Tracey & Cardenas, 1996; Wright &Feun, 1986) involved interventions using pre- and post-training tests of knowledge. Nine studies (Costello et al.,1997; Hart et al., 1996; Howes et al., 1996; Medeiros et al.,1996; Nabali et al., 1986; Reicks et al., 1994; Sparkman,Briley, & Gillham, 1984; Tracey & Cardenas, 1996; Waddell& Rinke, 1985) found statistically signiWcant improvementsin the test scores of the intervention groups, whilst a furthertwo (Laverack, 1989; Wright & Feun, 1986) measured someimprovement. Two studies (Ehiri et al., 1997b; Reicks et al.,1994) found a signiWcant diVerence between the interven-tion and control group. Only one intervention (Powell,

Attwell, & Massey, 1997) measured no signiWcant diVerencein post-training scores.

The results from those studies not involving any inter-vention also varied. These were frequently based on ques-tionnaires and results ranged from good knowledgethrough to poor knowledge in critical aspects of foodsafety. Generally there was good awareness of commonfood pathogens (Al-Dagal, 2003; Angellilo, Viggiani,Greco, Rito, & the Collaborative group, 2001), but poorknowledge of temperature control, especially regardingreheating and cooling (Manning & Snider, 1993; Zain &Naing, 2002).

In summary it is very diYcult to make any direct com-parisons as the studies were all conducted in diVerent ways,involving diVerent tests. Of the 21 studies where a trainingintervention was included, four (Cotterchio, Gunn, CoYll,Tormey, & Barry, 1998; Kirby & Gardiner, 1997; Palmer,Hatlen, & Jackson, 1975; SoneV et al., 1994) did not use anyknowledge tests to evaluate the training.

4.2. Attitudes, behaviour and work practices

Very few of the studies reviewed included any detailedinvestigation of attitude, a cognitive element that may inXu-ence food safety behaviour and practice. Again any directcomparison of results is diYcult because of the disparity ofthe measures used in the reported studies. The means ofevaluating attitudes, behaviour and work practices fall intotwo broad categories, namely surveys or inspections of pre-mises and structured questionnaires. Seventeen of the stud-ies included a premises survey or observation of behaviour,and Wve studies (Cook & Casey, 1979; Cotterchio et al.,1998; Kneller & Bierma, 1990; Powell et al., 1997; Wright &Feun, 1986) used routine inspection scores. In someinstances this was the sole measure of behaviour andhygiene practices. The exact range of the surveys varied butusually included inspection of physical facilities and assess-ments of cleaning procedures, personal hygiene and

Table 5Food hygiene training evaluation studies using a randomised controlled experimental design

Study and year Country Participants (number) Training intervention Knowledge Attitude, behaviour andworking practices

Ehiri et al. (1997b) Scotland Intervention group (n D 188)and comparison group (n D 204)who receive no training

REHIS elementary foodhygiene course

Self-administered testof 20 questions

Not assessed

Reicks et al. (1994) USA Leaders of home studygroups (nD 97)

Food safety instruction(2 h lesson)

Thirteen multiple choicequestions, pre- andpost-instruction

Pre- and post-instructionevaluation of attitudes tofood safety, using 5-pointLikert scale

SoneV et al. (1994) Canada StaV at 46 communitybased adult care facilities

Training workshop plusmanual, manual only orno intervention

Not assessed Pre- and post-trainingassessment of staV practices

Waddell andRinke (1985)

USA Food service employees(n D 230) at large military hospital

Computer assisted training(CAI) and lecture methodof instruction (LMI)

Pre- and post-testquestionnaire,33 questions

Questionnaire to assessattitude to training usingLikert scale

Wright andFeun (1986)

USA Food service managers (n D 54);study group (n D 27) and controlgroup (n lD 27)

NIFI training programme Pre- and post-tests used Pre-inspection of premises;two post-inspections soonafter course

1186 M.B. Egan et al. / Food Control 18 (2007) 1180–1190

temperature control. Quite often premises were assigned aninspection score, most usually when the study involve a pre-and post-training inspection.

Questionnaires or interviews were used to documentself-reported food hygiene practices and attitudes to foodhygiene and training. Attitudes were measured most com-monly using a 5-point Likert scale. Less frequently studiesincorporated researcher observation of food safety prac-tices on site. In one study (Howes et al., 1996) 16 practiceswere observed prior to training but this was reduced to twopractices post-training because of inherent diYculties withcompleting these observations. In three studies (Little, Bar-nes, & Mitchell, 2002; Tebbutt, 1986; Tebbutt, 1991) micro-biological sampling was used as a measure of eVectiveness.

A number of interesting results do emerge. The majorityof food handlers and managers expressed a positiveattitude to food safety but this was not supported by self-reported practices (e.g. Angellilo, Viggiani, Rizzio, &Bianco, 2000). Furthermore some studies have demon-strated the discrepancy between self-reported behaviourand observed or actual behaviour (Clayton, GriYth, Price,& Peters, 2002; Oteri & Ekanem, 1989).

In studies using inspections/surveys of premises four ofthe Wve studies using routine inspection scores (Cook &Casey, 1979; Cotterchio et al., 1998; Kneller & Bierma,1990; Wright & Feun, 1986) found a signiWcant improve-ment in post-training inspection scores. In the Cook &Casey study however the improved inspection score wasnot signiWcantly higher than that of control establishments.Other studies using inspections (e.g. Kirby & Gardiner,1997) reported no signiWcant improvements. Furthermorethere seemed to be no correlation between knowledge testscores and hygiene inspection scores (e.g. Cook & Casey,1979; Powell et al., 1997).

In one UK study (Little et al., 2002) the presence of atrained manager improved food safety procedures and inone US study (Cotterchio et al., 1998) the mandatory atten-dance of managers resulted in improved inspection scores. Apoor correlation emerged between microbiological examina-tions and visual inspections (Tebbutt, 1986, 1991).

4.3. Retraining and duration of eVects

Retraining or refresher training featured in only fourstudies (Holt & Henson, 2000; Tebbutt, 1991, 1992; Wors-fold & GriYth, 2003). Three studies (Holt & Henson, 2000;Tebbutt, 1992; Worsfold & GriYth, 2003) checked on thefrequency of refresher training whilst the fourth study(Tebbutt, 1991) assessed the management attitude toretraining as part of an interview. In one UK study (Teb-butt, 1992), 41% of the businesses involved oVered very lim-ited or no retraining whilst a more recent UK study(Worsfold & GriYth, 2003) reported very little refreshertraining being carried out.

Thirteen studies included some measure of the impact oftraining over time. The time period used for those studies(Costello et al., 1997; Hart et al., 1996; Laverack, 1989;

Medeiros et al., 1996; SoneV et al., 1994; Sparkman et al.,1984; Sumbingco, Middleton, & Konz, 1969; Worsfold,1993; Wright & Feun, 1986) ranged from one week to sixmonths. When an inspection was the measure, the timeperiod increased up to Wve years (Cotterchio et al., 1998;Kneller & Bierma, 1990; Wright & Feun, 1986). Two USstudies (Cotterchio et al., 1998; Kneller & Bierma, 1990)reported that improvements in inspection scores were sus-tained for 18–24 months and only began to decline afterthree years. However another study from the US reported areduction in post-training performance after only eightweeks (Sparkman et al., 1984) whilst another foundreduced inspection scores after six months (Wright & Feun,1986).

4.4. HACCP training studies

A search of the food safety literature identiWed only Wvestudies that involved some evaluation of HACCP training,these included a HACCP training programme in theLithuanian dairy industry (Boccas et al., 2001), a survey ofHACCP implementation in Glasgow (Ehiri, Morris, &McEwen, 1997a) and an evaluation of a short HACCPcourse involving representatives from residential carehomes (Worsfold, 1998). A lack of food hygiene knowledgeby staV was identiWed as the greatest problem in a study ofthe application of HACCP in a Xight catering establish-ment (Lambiri, Mavridou, & Papadakis, 1995). Trainingwas seen as critical in order to assess hazards and controlfood safety in the long-term. In a study of cleaning stan-dards and practices in 1502 food premises in the UK(Sagoo, Little, GriYth, & Mitchell, 2003a), deWciencies wereassociated with premises that did not have managementfood hygiene training or hazard analysis. Education andtraining is crucial in implementing any HACCP system.This has been recognised previously by both the Codex(1997) and NACMCF (1998) and is now more relevant inthe UK with the introduction of new hygiene legislation.

5. Discussion and conclusions

This review particularly focused on studies thatattempted to evaluate the eVectiveness of food safety andhygiene training. Other reviews of eVective food safetytraining support many of the Wndings from the studiesexamined here.

A number of reviews (Riben, Mathias, Campbell, &Wiens, 1994; Riben, Mathias, Wiens, et al., 1994; Mathiaset al., 1994) undertook critical appraisals of the literaturerelating to food safety education in Canada, focusing onroutine restaurant inspections and education of food han-dlers. They identiWed thirteen studies but many were weak,lacking in methodological detail and with poorly deWnedoutcomes. They concluded that training had an impact onexamination scores and restaurant inspection scores in theshort-term. It was impossible to deWne a particular educa-tional intervention as most eVective due to diVerences in

M.B. Egan et al. / Food Control 18 (2007) 1180–1190 1187

those used and lack of controls. In a follow up study, Math-ias, Sizto, Hazelwood, and Cocksedge (1995) examined theeVects of inspection frequency and food handler educationon restaurant inspection violations. Those restaurants withany staV having food handler education did signiWcantlybetter on the overall inspection score than those with staVwho had no such education.

In a further review of the eVectiveness of Canadian pub-lic health interventions in food safety 15 studies were exam-ined and three categories of interventions identiWed(Campbell et al., 1998). These were inspections, food han-dler training and community-based education. Once againthere was some evidence that interventions can result inimproved food safety, but the authors emphasize thatbecause of diVerences in protocols many studies are notuseful in establishing guidelines.

This work was recently extended (Mann et al., 2001) andnow includes 55 papers of which seven were rated as mod-erate and 48 rated as weak. The authors concluded thatfour of the seven studies provided good evidence to supportthe eVectiveness of the food safety interventions with posi-tive results for the main outcome measured. Five of theseven studies included in the review focused on food han-dler training and or certiWcation, three of which (Cotterchioet al., 1998; Rinke et al., 1975; Waddell & Rinke, 1985) pro-vided evidence for the eVectiveness of the intervention.

Several other reviews have attempted to identify the keyfeatures of an eVective training programme (Sprenger,1991; Rennie, 1994; Taylor, 1996). Training in the work-place is one such feature. Current training is often con-ducted away from the workplace and there may bediYculties in translating theory into improved food han-dling. Rennie (1994) concluded that the need for improve-ments in food handling practices might be better served bytraining in the workplace, allowing for practical reinforce-ment of the hygiene message. Taylor (1996) reiterated this,arguing that the impact of food handler training is minimaland would be more eVective if conducted in the workplace,where it can be job speciWc. She cites the minimal eVect oftraining courses on knowledge, attitudes and behaviour offood handlers as well as their inability to inXuence opera-tional practices.

Another critical issue is that of eVective managementtraining. In an evaluation of a fast food management train-ing programme Jackson, Hatlen, and Palmer (1977), con-cluded that management training can be eVective if it isadministered on a continuous basis, supported by the own-ers and includes frequent follow-up. Nabali et al. (1986),concluded from their study that training of managers waseVective in improving hygiene standards. A microbiologicalstudy of open, ready-to-eat, prepared salad vegetables fromretail or catering premises by Sagoo, Little, and Mitchell(2003b), identiWed a direct relationship between foodhygiene training of management, increased conWdence inthe food business management and the presence of foodsafety procedures. In a study of ready-to-eat stuYng fromretail premises in the northeast of England, Richardson and

Stevens (2003) suggested that poor microbiological qualityof product might be related to management food hygienetraining and conWdence in management scores. Sprenger(1991) argues that prioritising the training of managers maybe more important than that of basic food handlers. Thenumerous beneWts of management training include the abil-ity of managers to inXuence premises hygiene, less turnoverof managers and their impact on the training of staV.Whereas training food handlers has had minimal impact,training managers may be more cost eVective, premiseshygiene is more within their remit and managers canself-inspect and train employees (Taylor, 1996). However aprevious study of 300 professionally qualiWed cateringmanagers does not support many of these assertions(Taylor, 1994). The results suggested that trained managersdid not put their theoretical knowledge into practice oralternatively did not possess the knowledge that their quali-Wcation should have delivered. Ultimately the training didnot result in the implementation of critical food safetypractices in the workplace.

A further issue to arise from US studies is that of man-datory training. Penninger and Rodman (1984) addressedthis issue by determining the eVectiveness of both voluntaryand mandatory food service managerial certiWcation train-ing programs in a limited random study. Mandatory pro-grammes were more successful in certifying managers thanvoluntary programs with 91% of mandatory agenciesclaiming improvement in inspection scores, compared to33.3% of voluntary agencies. However these Wndings werebased on a response rate of less than 35% of the agenciessurveyed. In an evaluation of the Ohio Food service man-ager certiWcation course (Clingman, 1976), there was a 5.5%improvement in overall sanitation level for those restau-rants whose managers had been certiWed. This compared toa 3.3% improvement for restaurants whose mangers werenot certiWed. This study also noted that management turn-over in non-certiWed manager establishments was 29.7%,whereas that in certiWed manager establishments was 19.5%over the study period. Similarly, the voluntary nature of theMinnesota Quality Assurance Programme for the Preven-tion of Foodborne Illness reduced its eVectiveness (Heenan& Synder, 1978). Burch and Sawyer (1991), also recom-mended mandatory training based on their Wnding that thesanitary condition of stores was closely associated with thefood safety knowledge of management.

The importance of training food handlers is acknowl-edged by many as critical to eVective food hygiene yet therehave been limited studies on the eVectiveness of such train-ing. Many of the authors recommend approaches that mayresult in improved food handling practices. Rennie (1995)suggests that behavioural change would be more likely ifthe settings approach to health promotion were adopted infood premises.

Studies involving an assessment of food hygiene trainingwere included in this review. It is very diYcult to make anydirect comparisons between studies because of the varieddesigns and outcome measures used. Within the various

1188 M.B. Egan et al. / Food Control 18 (2007) 1180–1190

measures there was much variation and incomplete report-ing of the details of the intervention methods and outcomemeasures. For example, few studies reported details of thequestionnaires used. The majority of the studies were onlyshort-term and while these can provide useful information,longer-term interventions and evaluations are needed toassess behavioural change. Another limitation of the stud-ies involving interventions was the lack of information oncosts or cost-eVectiveness, an issue often cited as a barrierto training.

The limitations of measures used to assess training inter-ventions are further discussed by Ehiri and Morris (1996).They found the use of pre- and post-training test scores lim-ited for evaluation purposes as they often measure knowl-edge of items not reXected in behaviour change. They alsohighlighted the lack of correlation between examinationscores and improvements in food safety by reference to thestudies of Luby, Jones, and Horan (1993) and Laverack(1989). The use of food hygiene inspection scores as ameans of evaluation is limited by the lack of correlationbetween training and inspection scores. It is worth notingalso that these studies were based solely in the commercialsector. Commercial food safety is very dependant on organ-isational structures and cannot easily be related to individ-ual behaviour.

EVorts to reduce the incidence of foodborne illnessthrough interventions have had mixed results. The focus ofinterventions, in the commercial sector, has been onimproving food handling practices. A primary aim andtherefore a primary criterion for evaluation of any trainingis a change in behaviour towards less risky food handlingpractices. A related goal is to improve knowledge about foodsafety practices such as cross-contamination, temperaturecontrol and personal hygiene. Related to these is the issueof measuring outcomes. The principal conclusions of thisreview of the literature are:

Current evidence for the eVectiveness of food hygienetraining is limited. This review has shown that many of thestudies on food hygiene training are limited both by a lackof methodological detail and of well deWned outcomes,Comparisons between studies are restricted and it becomesimpossible to deWne eVective interventions due to thesediVerences. There is a need to identify meaningful perfor-mance indicators at an individual level that can be used tomeasure the eVectiveness of food hygiene training.

Questionnaires are a convenient measure of knowledgeand attitudes but direct observation has limited value. Reli-able data from the workplace is essential to develop, imple-ment and evaluate eVective food hygiene training, howeverinformation on food hygiene behaviours obtained by directobservation has limited value. Such observations are usu-ally restricted to a small number of practices because of thevariety and complexity of roles involved in food handling.StaV may also exhibit altered behaviours in the presence ofthe observer to present what is perceived to be a more desir-able image. There are also practical considerations in rela-tion to time and cost involved in such observations.

Evaluation of training is essential and factors other thantraining content and design are important. It is necessary tolook beyond the training context to understand how andwhy training does or does not work. Issues such as manage-rial support, the availability of equipment and tools, train-ing and pre-training motivation can all inXuence the extentto which individuals react to the training experience. Train-ing outcomes will also be inXuenced by a host of other fac-tors, both organisational and individual. These may includecultural dimensions, legislation, environmental.

Training of managers can be eVective in reducing foodsafety problems. The training of managers is seen by manyas a necessary precursor to the implementation of realisticfood safety practices within the workplace. If managerswere trained to advanced levels they would then providebasic training for food handlers in-house and make trainingmore sector speciWc. The eVectiveness of training is verydependent on both management attitude and their willing-ness to provide the resources and systems for food handlersto implement good practice.

Evidence from the literature suggests that food hygienetraining as a means of improving food safety standards islimited by a lack of understanding of those factors contrib-uting to successful outcomes. There is a need to developtraining methods that are proven to change behaviour aswell as imparting knowledge. Further research is needed onissues including course content, the site of training, dura-tion of courses and refresher training. Such research needsto be clearly thought out, well designed with good baselinedata to achieve worthwhile results.

Acknowledgement

This study has been carried out with Wnancial supportfrom the Food Standards Agency. It does not necessarilyreXect its views and in no way anticipates the Agency’sfuture policy in this area.

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