KNOWLEDGE, ATTITUDES, AND PRACTICES ON FOOD SAFETY AMONG FOOD HANDLERS OF SELECTED

GOVERNMENT AND PRIVATE HOSPITALS IN MANILA, PHILIPPINES

Chapter I

Introduction

The Department of Health (DOH) defined food safety as the “assurance/guarantee

that food will not cause harm to the consumers when it is prepared and/or eaten according

to its intended use” (DOH, 2006). Exposure to hazardous contaminants, the application of

novel processes and technologies and poor handling can render food unsafe for

consumption. A hazardous contaminant or hazard in food is any “biological, chemical or

physical agent in, or condition of, food with the potential to cause an adverse health

effect” (FAO/WHO, 2006 b).

The WHO has listed food safety as an increasingly important public health issue

(WHO, 2007), hence, governments all over the world are intensifying their efforts to

improve food safety. These efforts are in response to an increasing number of food safety

problems and rising consumer concerns specifically foodborne illnesses which can be

traced from the consumption of unsafe food.

The World Health Organization (WHO, 2007) defined foodborne diseases as

diseases, usually either infectious or toxic in nature, caused by agents that enter the body

through the ingestion of food. It is a widespread and growing public health problem,

both in developed and developing world. Epidemiological and surveillance data suggest

that faulty practices in food processing plants, food service establishment and home lay a

2

crucial role in the causal chain of foodborne diseases. This has also affected hospitals in

some nosocomial foodborne outbreaks. (Guallar et al, 2004; Sion et al, 2000; Maguire et

al, 2000)

Investigation of foodborne disease outbreaks throughout the world show that, in

nearly all instances, they are caused by failure to observe satisfactory standards in the

preparation, processing, cooking, storing or retailing of food. (WHO, 1989). In Malaysia,

approximately 10-20% of foodborne disease outbreaks are due to contamination by the

food handlers. (Zain and Naing, 2002). Therefore, food handlers, have a critical role in

maintaining food safety. There are several ways in which a food handler may

contaminate the food with pathogens, hence serving as a link between food borne

diseases and the consumer.

Mishandling food in hospitals can permit proliferation of microorganism that

cause such illness, especially among patients with impaired immunity (Askarian et al,

2004). Such diseases could also lead to other potential problems like malnutrition

whereby gastroenteritis can impair digestion and absorption of nutrients and the

perception or fear about poor food hygiene practices might result in patients rejecting the

meals supplied by the hospital catering (Barrie, 1996; Richards, 1997) thereby putting

more burden on the hospitalized patient and their family as well. Thus, development of

food safety education program is an important aspect of ensuring that food handlers are

knowledgeable and capable of food safety and sanitation principles.

3

This study will be conducted with the aim of exploring the sociodemographic

characteristics of food handlers in selected government and private hospitals in Manila,

Philippines and determining their knowledge, attitudes and practices (KAP) on food

safety. The results of the study will help in formulating food safety education program

for food handlers especially those working in government hospitals. Private hospitals

will be included in the study to determine if there exists difference as compared with

government hospitals in their characteristics and KAP on food safety.

II. Research Objectives

General Objective:

To determine the knowledge, attitude, practices on food safety among food

handlers in selected government and private hospitals in Manila, Philippines.

Specific objectives:

1. To determine the knowledge of food handlers on:

a. Food borne pathogens

b. Food-borne diseases transmission

c. Proper food hygiene and sanitation

2. To determine the attitude of food handlers towards food safety:

3. To determine the practices of food handlers on:

a. Food processing

b. Food and personal hygiene

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4. To determine the sociodemographic characteristics of food handlers

5. To determine the association of food safety knowledge, attitude, and practices

with some socio demographic characteristics

6. To compare the KAP on food safety and selected sociodemographic

characteristics between food handlers employed in government and private

hospitals.

III. Review of Literature

Food is any substance which when eaten nourishes the body and sustains life.

Along with shelter and clothing, it is a basic necessity of a person. However, problems

may arise on its preparation thereby affecting the safety of foods available for

consumption. Such problems are common and has persisted which resulted in morbidity

and mortality cases (WHO, 1998).

Food safety

The Department of Health (DOH) defined food safety as the “assurance/guarantee

that food will not cause harm to the consumers when it is prepared and/or eaten according

to its intended use” (DOH, 2006). This definition is consistent with that of the Food and

Agriculture Organization of the United Nations (FAO, 1999), in example “Food safety”

implies absence or acceptable and safe levels of contaminants, adulterants, naturally

occurring toxins or any other substance that may make food injurious to health on an

acute or chronic basis.”

5

Previous to this the FAO together with the World Health Organization jointly

defined food safety as “all conditions and measures that are necessary during the

production, processing, storage, distribution, and preparation of food to ensure that it is

safe, sound, wholesome, and fit for human consumption”(FAO/WHO, 1996).

Exposure to hazardous contaminants, the application of novel processes and

technologies and poor handling can render food unsafe for consumption. A hazardous

contaminant or hazard in food is any “biological, chemical or physical agent in, or

condition of, food with the potential to cause an adverse health effect” (FAO/WHO, 2006

b).

Food safety is an increasingly important public health issue (WHO, 2007).

Governments all over the world are intensifying their efforts to improve food safety.

These efforts are in response to an increasing number of food safety problems and rising

consumer concerns specifically foodborne illnesses which can be traced from the

consumption of unsafe food.

Philippine Republic Act 10611 – Food Safety Act of 2013

It is important to strengthen the food safety regulation to protect consumers’ health.

According to Article I, Section 3 of the Philippine Republic Act 10611, also known as the

Food Safety Act of 2013, which was signed by President Benigno S. Aquino III on

August 23, 2013, food safety regulatory system in the country should be strengthen

through adopting the following specific objectives:(a) Protect the public from food-borne

and water-borne illnesses and unsanitary, unwholesome, misbranded or adulterated

foods; (b) Enhance industry and consumer confidence in the food regulatory system; and

6

(c) Achieve economic growth and development by promoting fair trade practices and

sound regulatory foundation for domestic and international trade.

Towards the attainment of these objectives, the following measures shall be

implemented:(1) Delineate and link the mandates and responsibilities of the government

agencies involved; (2) Provide a mechanism for coordination and accountability in the

implementation of regulatory functions; (3) Establish policies and programs for

addressing food safety hazards and developing appropriate standards and control

measures; (4) Strengthen the scientific basis of the regulatory system; and (5) Upgrade

the capability of farmers, fisher folk, industries, consumers and government personnel in

ensuring food safety. (6) The normal conditions of the use of food by the consumer; (7)

The normal conditions maintained at each stage of primary production, processing,

handling, storage and distribution; (8) The health of plants and animals from where the

food is derived; (9) The effect of feeds, crop protection chemicals and other production

inputs on otherwise healthy plants and animals; and (10) The information provided to the

consumer. This includes the information provided on the label or any information

generally available to the consumer. This should aid consumers in avoiding specific

health effects from a particular food or category of food.

(b) In determining whether food is unfit for human consumption, regard shall be

given to the unacceptability of the food according to its intended use due to

contamination by extraneous matter or through putrefaction, deterioration or decay;

(c) Where unsafe food is part of a batch, lot or consignment of food of the same class

or description, it shall he presumed that all food in that hatch, lot or consignment is also

unsafe;

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(d) Food that complies with specific national law or regulations governing food safety

shall be deemed safe insofar as the aspects covered by national law and regulations are

concerned. However, imported food that is declared unsafe by the competent authority of

the exporting country after entry into the country shall be withdrawn from the market and

distribution channels; and

(e) Compliance of a food product with specific standards applicable to a specific food

shall not prohibit the competent authorities to take appropriate measures or to impose

restrictions on entry into the market or to require its withdrawal from the market, where

there is reason to suspect that such food product shows food safety related risks.

To ensure food safety, an accreditation for food safety standard was set. The

Department of Agriculture (DA) and the Department of Health (DOH) shall set the

mandatory standards in accordance to the Act under Article IV Section 9 of RA 10611.

The following shall guide the setting of standards:

Standards shall be established on the basis of science, risk analysis, scientific advice

from expert body/bodies, standards of other countries, existing Philippine National

Standards (PNS) and the standards of the Codex Alimentarius

Commission (Codex), where these exist and are applicable.It shall be adopted except

when these are in conflict with what is necessary to protect consumers and scientific

justification exists for the action taken.In addition, the Department of Agriculture (DA)

and the Department of Health(DOH) shall establish the policies and procedures for

country participation at Codex and the incorporation of Codex standards into national

regulations. Moreover, the current National Codex Organization (NCO) is herein

designated as the Body to serve this purpose. The DA and the DOH shall designate a

8

third level officer as coordinator for Codex activities for their respective departments.

Participation at Codex shall be in accordance with the principles of this Act and shall be

financially supported by the government.

Mandatory training on safe food handling and similar courses shall be implemented

for food handlers of food businesses, most especially to the establishments placed inside

elementary schools. Government personnel shall be trained on the scientific basis for the

provisions of the law and on the conduct of official controls. The frequency of

inspections shall be based on the assessment of risks. Establishments producing high-risk

foods or carrying out high-risk activities shall be inspected more frequently. Inspectors

shall have defined skills on risk-based inspection and shall be regularly evaluated based

on suitable procedures to verify their continuing competence. Appropriate procedures

shall be in place to ensure that the results of inspection are interpreted in a uniform

manner, stated in Article VIII, also known as the Implementation of Food Safety

Regulations.

The departments involved in the food control system in the Philippines are the

Department of Health, Agriculture and Natural Resources. The Bureau of Food and

Drugs under the Department of Health and National Meat Inspection Commission under

the Ministry of Agriculture are the two agencies most responsible for ensuring the safety

of the country’s food supply. Supportive activities are rendered by The Environmental

Sanitation Division of the Bureau of

The Bureau of Food and Drugs oversees the control of the manufacturing and sale of

processed foods, where the major concerns are adulteration and mislabeling of food

products. It is responsible for the surveillance of imported food products at legal ports of

9

entry. The National Meat Inspection Commission supervises the operation of abattoirs

and meat establishments engaged in the sale and preparation of food in public markets,

restaurants and other food premises is the responsibility of the Environmental Sanitation

Division.

Basic laws are embodied in the following legislative acts and presidential decrees:

(1.)Food, Drug and Cosmetic Act (RA 3720) generally provides for the adoption of

measures to ensure a pure and safe supply of food, to protect the health of the people and

for the promulgation of food standards. The Bureau of food and Drugs is implementing

agency. (2.)Presidential Decree No. 856 or the Code on Sanitation covers the sanitation

of food service establishments. (3.)All food establishments are required to obtain a

license to operate, inspection, which is renewable annually. Food establishments, when

found operating under unhygienic conditions or not in accordance with the guidelines of

Good Manufacturing Practices (GMP), are required to stop their operation, and the

license is suspended. If the management fails to institute corrective measures, the license

to operate may be permanently revoked. To monitor the health of food handlers, such

persons are required to obtain a health certificate before they are employed.

The following section presents some important provisions embodied in

Presidential Decree No.856 (Code on Sanitation of the Philippines, 1975), and these are

follows:

Sec. 15. Health Certificates. - No person shall be employed in any food

establishment without a Health Certificate issued by the local health authority. This

certificate shall be issued only after the required physical and medical examinations are

performed and immunizations are administered at prescribed intervals.

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Sec. 16. Quality and Protection of Food. - All food must be obtained from sources

approved by the local health authority. In this regard, the following

requirements are applicable:(a) Meats, meat products and fish shall be procured for

sources under sanitary or veterinary supervision; (b) All meat and fish shall be properly

cooked before serving; (c) No meat products fish, vegetables and other food sources shall

be procured from sources or areas known to have been affected by radioactivity as for

example, areas contaminated with a very large amount of radioactive fallout; (d) Milk

and fluid milk products shall be obtained from sources approved by the local health

authority. Milk obtained from other sources must be sterilized, pasteurized or otherwise

heated; (e) Milk shall be stored in a refrigerator. Canned or packaged milk, other than

milk powders, shall be refrigerated after the container has been opened; (f) All perishable

and potentially hazardous foods shall be stored at 45°F (7°C) or below; (g)Cooked food

intended to be served hot shall be kept at a temperature not lower than 140°F (60°C ); (h)

Raw fruits and vegetables shall be thoroughly washed before they are used.

Sec. 17. Structural Requirements. - Food establishments shall be constructed in

accordance with the following requirements:(1.) No person shall use any room or place

for or in connection with the preparation, storage, handling or sale of any article of food:

(a) Which is at anytime used or in direct communication with a sleeping apartment or

toilet; or (b) In which any animal is kept; or(c) which is or has been used for any purpose

which would be likely to contaminate the food or to affect injuriously its wholesomeness

or cleanliness; or (d) Which is not used exclusively for the purpose: Provided, that in

department stores or multi-purpose business establishments, food may be manufactured,

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prepared, cooked, stored, or sold only in the area set aside exclusively for said purpose

and for which a sanitary permit has been issued.

Sec. 18. Use of Food-Service Spaces: (a) Food-service spaces shall not be used as

living or sleeping quarters; (b) Clothing or personal effects shall be kept in lockers or in

designated places away from food service spaces; (c) No animal or live fowls shall be

allowed in such spaces; (d.) Persons not directly connected with food preparation and

serving shall not be allowed to stay in food-serving spaces; (e) Foods in storage or in

preparation must not be handled by anyone other than the preparation and serving staff.

SEC. 19. Food Handlers: (a.) No person shall be employed in any food

establishments without health certificate issued by the local health authority.

Sec. 20. Vermin Control: (a.) Spaces where food and drinks are stored, prepared

and served shall be so constructed and maintained as to exclude vermin; (b) All opening

which connects spaces to the outer air shall be effectively protected with screen of non-

corrosive wire 16-mesh or finer. Door screens shall be tight-fitting; (c) A vermin

abatement program shall be maintained in the establishments by their owners, operators,

or administrators. If they fail, neglect or refuse to maintain a vermin abatement programs,

the local health agency will undertake the work at their expense; (d) During disinfecting

operations, all food stuffs, utensils, food preparation and cleaning equipment shall be

covered to protect them from toxic chemical substances; (e) Vermin control in public

places shall be the responsibility of the provincial, city or municipal governments which

have jurisdiction over them; (f) The procedure and frequency of vermin abatement

program shall be determined and approved by the local health authority.

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Sec. 23. Equipment and Utensils: (a.) They shall be so designated, fabricated and

installed so that cleaning is easy and they do not pose health hazards; (b) Lead-soldered

containers and cadmium-lined piping and fixtures shall not be used; (c) Surfaces that

come into contact with food or drinks shall be constructed or materials that are

impervious, corrosion-resistant, non-toxic, easily cleanable, durable and resistant to

chipping.

Sec. 25 Bactericidal Treatment-Eating and drinking utensils and equipment, after

thoroughly cleaned, shall be subjected to one of the following bactericidal treatments:(a)

Immersion for at least half a minute in clean hot water at a temperature of at least 170°F

(77°C);(b) Immersion for at least one minute in a lukewarm chlorine solution 50ppm;(c)

Exposure in a steam cabinet at a temperature of at least 170°F (77°C) for at least 15

minutes at a temperature of 200°F (90°C) for at least 5 minutes;(d) Exposure in an oven

or hot-air cabinet at a temperature of at least 180°F (82°C ) for at least 20 minutes; or(e)

Any other method approved by the local health authority.

Sec. 26. Handling of Washed Utensils: (a) Washed utensils shall be allowed to

drain dry in wire racks without use of drying cloths, or shall be stored in self-draining

position to permit ready air-drying; (b) The drying cloth on which to store dishes and

utensils temporarily after bactericidal treatment should be clean and changed frequently.

Sec. 27. Storage of Washed Utensils: (a) They shall be stored in a clean and dry

place protected against vermin and other sources of contamination; (b) Cups, bowls, and

glasses, shall be inverted for storage; (c) When not stored in closed cupboards or lockers,

utensils and containers shall be covered or invented whenever practicable. Utensils shall

not be stored on the bottom shelves of open cabinets below the working top level; (d)

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Racks, trays and shelves shall be made of materials that are impervious, corrosion-

resistant, non-toxic, smooth, durable and resistant to chipping; (e) Drawers shall be made

of the same materials and kept clean. Felt-line drawers are not acceptable, but the use of

clean and removable towels for lining drawers is acceptable.

Sec. 29. Refrigerated Storage of Perishable Foods. - Perishable foods shall be

stored in the following manner:(a) They shall be kept at or below 45°F (7°C) except

during preparation or when held for immediate serving after preparation; (b)

When such food s are to be stored for extended periods, a temperature of 40°F (4°C) is

recommended; (c) Fruits and vegetables shall be stored in cool rooms; (d) All

refrigerating compartments and refrigerators must be kept clean, in good repair and free

from odors. They shall be provided with thermometers with scale divisions not larger

than 32°F (1°C). Sufficient shelving shall be provided to prevent stocking and to permit

adequate ventilation and cleaning.

Sec. 30. Food Servicing Operations. - These operations should be in accordance

with the following requirements: (a) Hand contacts with food or drink shall be avoided;

fingers shall not be used to serve butter, ice, or similar items or food. Sugar shall be

served in covered dispensers or containers, or in packages wrapped for single service; (b)

The surfaces of containers and utensils, including glasses and tableware, which come in

contact with food and drink shall not be handled.

Foodborne diseases

The World Health Organization (WHO, 2007) defines foodborne diseases as

diseases, usually either infectious or toxic in nature, caused by agents that enter the body

14

through the ingestion of food. It is a widespread and growing public health problem,

both in developed and developing world. It has also been reported that in 2005 alone, 1.8

million people died from diarrhoeal diseases. A great proportion of these cases can be

attributed to contamination of food and drinking water. Additionally, diarrhea is a major

cause of malnutrition in infants and young children.

Developing countries bear the brunt of the problem due to the presence of a wide

range of foodborne diseases, including those caused by parasites. The high prevalence of

diarrhoeal diseases in many developing countries suggests major underlying food safety

problems. On the other hand, industrialized countries are not spared from this problem

since the percentage of their population suffering from foodborne diseases each year has

been reported to be up to 30%. (WHO, 2007).

Foodborne diseases create an enormous social and economic burden on

communities and their health systems. In the USA, diseases caused by major pathogens

alone are estimated to cost up to US $35 billion annually (1997) in medical costs and lost

productivity. The re-emergence of cholera in Peru in 1991 resulted in the loss of US

$500 million in fish and fishery product exports that year. (WHO, 2007).

Epidemiological and surveillance data suggest that faulty practices in food

processing plants, food service establishment and home lay a crucial role in the causal

chain of foodborne diseases. This has also affected hospitals in some nosocomial

foodborne outbreaks. (Guallar et al, 2004; Sion et al, 2000; Maguire et al, 2000)

In the Philippine settings; food borne infections such as gastroenteritis and all

forms of dysentery are notifiable diseases. Every physician, director, superintendent or

person-in-charge of a hospital, educational institution and personal hygiene. Residential

15

building or industrial establishment shall notify the nearest health station of the

occurrence of the disease, indicating the name and address of the affected person.

(Disease Intelligence Center of DOH 2010-2012.)

The human and animal occupants of the home can also serve as sources of food-

borne pathogens. Humans and animals can both serve as symptomatic and non-

symptomatic carriers and also as post symptomatic excreters. Pathogens can be

transferred from various sources to inanimate contact surfaces in the home or directly to

other foods or human occupants via transient carriage on the hands. Food-borne agents

that have been introduced into the home via human include species of Salmonella,

Shigella sonnet, Staphylococcus aureus, rotavirus and hepatitis A virus (Code of

sanitation PD 856 Section 7)

Bacterial food infections occur when individuals eat food contaminated with large

colonies of bacteria. Specific bacteria cause specific diseases. Following are descriptions

of five common bacteria causing food-borne illness:

(1.)Escherichia coli 0157: This microorganism inhabits the intestines of animals

and humans. Most types of E. coli are benign, and some even do nutritionally important

work such as fermenting resistant starch. However, other strains such as E. coli 0157:H7

has emerged as a major cause of individual cases and large outbreaks of inflammatory

diarrheal associated with bloody stool and fever. Serious infections can result in kidney

impairment of death. E. coli 0157:H7 is destroyed by heat, and most outbreaks occur

from unpasteurized or undercooked foods. (Hammenger, 2009)

(2.)Salmonella: These bacteria were first isolated and identified by Daniel Salmon

(1850-1914) and are a common cause of human food-borne infection.

16

Salmonella bacteria grow quickly in high protein foods such as milk, custard, egg

dishes and sandwich filling. Seafood, especially shellfish such as oyster and clams from

polluted waters can be a source of infection. The contaminated egg with salmonella

enteritidis is a worldwide problem. Persons of all ages should avoid eating raw cookie

dough, drinking unpasteurized beverages containing milk or egg, or eating poorly cooked

eggs, but this is particularly important for older adults. According to the Centers for

Disease Control and Prevention, 40% of deaths from salmonella occur in people over the

age 65. Symptoms develop slowly, usually 12 to 24 hours after ingestion, and rage from

mild to bloody diarrhea with fever (Hammenger, 2009.)

(3.)Campylobacteriosis is an infectious disease caused by bacteria of the genus

Campylobacter. Symptoms of diarrhea, cramping, abdominal pain, fever and vomiting

usually occur two to five days after ingestion of the contaminated food or water. The

diarrhea may be bloody and the illness typically lasts one week. In persons with

compromised immune systems, Campylobacter occasionally spreads to the bloodstream

and causes a serious life-threatening infection. Incubation period is from 2 to 5 days. The

consumption of undercooked poultry and cross-contamination of other foods with

drippings from raw poultry are the leading risk factors for human campylobacteriosis.

Larger outbreaks due to Campylobacter are not usually associated with raw poultry but

are usually related to drinking un-pasteurized milk or contaminated water.

(4.)Shigella: The bacterium shigella was first discovered as the cause of dysentery

epidemic in Japan in 1898. Food-borne illness arising from shigella infection is usually

confined to the large intestine and varies from simple cramps and diarrhea to fatal

dysentery. Treatment with antibiotics may be required. Young children are a particular

17

risk of fatal complications. Shigella bacteria are found in contaminated water and the

intestinal tract of animals and are spread by insects and unsanitary food-handling

practices. They grow rapidly in moist or protein foods such as milk, beans, tuna, and

turkey. Apple cider or raw fruits and vegetables contaminated by animal droppings are

sources of Shigella bacteria. Foods need to be washed and cooked thoroughly and chilled

quickly to prevent infection.

(5.)Listeria: The bacterium Listeria has long been known as a major cause of

infection after surgery, but only recently was Listeriamonocytogenes linked with food-

borne illness. In older adults, pregnant women, infants, or those with suppressed immune

system, the organism produces diarrheal and flu like fever and headache. Related

complications such as pneumonia, sepsis, meningitis, endocarditis, and miscarriage

require medical intervention. Outbreaks of Listeria related illness have been traced to

unpasteurized dairy products, particularly soft cheeses made with unpasteurized milk.

Undercooked poultry foods have been implicated in Listeria infections. Through cooking

and careful washing of raw fruits and vegetables are preventive measures

(6.)Botulism: Botulism is a disorder caused by a toxic chemical produced by a

bacterium called Clostridium botulinum. This bacteria grows best in sealed containers

such as cans that have not been heated enough to kill the botulinium spores. The bacteria

grow best where there is little or no oxygen. It produces a toxin that can cause paralysis,

breathing failure, and even death. Patients ingesting this toxin can develop double vision,

drooping eyelids, slurred speech, difficulty swallowing, and difficulty breathing.

(Cataldo, E. N. 2009, Essential of Nutrition diet therapy 9th edition pg.78)

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Food handler

Food handlers have a critical role in maintaining food safety. The term food

handler was defined as a person in food trade or someone professionally associated with

it, such as an inspector who, in his routine work, comes into direct contact with food in

the course of its production, processing, packaging or distribution (WHO, 1989).

Investigation of foodborne disease outbreaks throughout the world show that, in

nearly all instances, they are caused by failure to observe satisfactory standards in the

preparation, processing, cooking, storing or retailing of food. (WHO, 1989). In Malaysia,

approximately 10-20% of foodborne disease outbreaks are due to contamination by the

food handlers. (Zain and Naing, 2002). There are several ways in which a food handler

may contaminate the food with pathogens, hence serving as a link between food borne

diseases and the consumer.

Mishandling food in hospitals can permit proliferation of microorganism that

cause such illness, especially among patients with impaired immunity (Askarian et al,

2004). Such diseases could also lead to other potential problems like malnutrition

whereby gastroenteritis can impair digestion and absorption of nutrients and the

perception or fear about poor food hygiene practices might result in patients rejecting the

meals supplied by the hospital catering (Barrie, 1996; Richards, 1997) thereby putting

more burden on the hospitalized patient and their family as well. Thus, development of

food safety education program is an important aspect of ensuring that food handlers are

knowledgeable and capable of food safety and sanitation principles.

Studies have also shown that only a very few number of food handlers have

received formal training on proper food handling (Azanza, 2000, Zain, 2002). Although

19

formal training resulted in better knowledge of the food safety, it seems that it does not

significantly affect the attitudes and practices of food handlers (Zain, 2002). Informal

food handlers studied in the past had good knowledge on hygiene but still showed poor

practices. It has been deduced that this poor practice resulted from lack of adequate

washing and waste disposal facilities. And because of the limited financial resources of

these informal food handlers, hygienic practices tend to be compromised (Azanza, 2000,

King, 2000, Vollaard, 2004).

Other authors have also found out that these informal food handlers had poor

knowledge when it comes to etiology and signs and symptoms of food borne illnesses

and continue to handle food even when they experience gastrointestinal symptoms like

diarrhea (Azanza, 2000, Zain, 2002). This allows contamination of food by pathogens

and subsequent transmission of food borne diseases.

This study will be conducted with the aim of exploring the sociodemographic

characteristics of food handlers in selected government and private hospitals in Manila,

Philippines and determining their knowledge, attitudes and practices (KAP) on food

safety. The results of the study will help in formulating food safety education program

for food handlers especially those working in government hospitals. Private hospitals

will be included in the study to determine if there exists difference as compared with

government hospitals in their characteristics and KAP on food safety.

20

IV. Conceptual framework

Independent Dependent

V. Methodology

A. Study design

This is a cross-sectional study which would utilize a research survey

questionnaire as the tool for data gathering casual face-to-face interview. The interview

would involve the administration of a standardized survey questionnaire which consists

of around 58 questions on food safety knowledge, attitudes, practices, socio-

demographics and other pertinent data among food handlers working in selected

government and private hospitals in Manila, Philippines

Knowledge of food handlers on:

1. Food-borne pathogens2. Food-borne diseases transmission3. Proper food hygiene and sanitation

Attitude of food handlers towards food safety

Practices of food handlers on: 1. Food processing3. Food and personal hygiene

Socio-demographicCharacteristics

1. Age2. Gender3. Civil status4. Highest educational attaintment5. Average monthly family income6. Acquired health certification7. Training on food safety8. Years of employment9. Type of Hospital

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B. Sampling design

The study shall employ a stratified, simple random, cluster sampling. The type of

hospital (government or private) will be the stratification variable. For each of the 2

types of hospital, a random sample of hospitals will be selected. All food handlers of the

sample hospitals will be included in the study.

Target population: Food handlers in both government and private hospitals in Manila,

Philippines.

Sample population: Food handlers of government and private hospitals in Manila,

Philippines.

Stratification variable: Type of hospital

Sampling frames needed to select the samples: List of government and private

hospitals

Elementary unit: Food handlers

C. Sample size determination

1. Knowledge (Adequate knowledge = 27.5%; Buccheri et al., 2007)Z = 1.96 d = 0.1P = 0.275 Q = 0.725

n = Z 2 PQ = (1.96) 2 (0.275)(0.725) d2 (0.1)2

n = 77 x 2 (type of hospitals) = 154

2. Attitude (Positive Attitude = 20%; Buccheri et al., 2007)Z = 1.96 d = 0.1P = 0.2 Q = 0.8n = Z 2 PQ = (1.96) 2 (0.2)(0.8) d2 (0.1)2

n = 61 x 2 (type of hospitals) = 122

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3. Practices (Good Practices = 53.2%; Buccheri et al., 2007)Z = 1.96 d = 0.1P = 0.532 Q = 0.468n = Z 2 PQ = (1.96) 2 (0.532)(0.468) d2 (0.1)2

n = 96 x 2 (type of hospitals) = 192

Note: Since there are 2 types of hospitals (government or private) sample size determination for Knowledge, Attitudes and Practices shall be multiplied by 2.

D. Operational Definition of variables

1. Income – gross monthly sales in pesos of household.

2. Years of employment – number of years working on the hospital

3. Type of hospital – Government or Private hospital.

4. Health certificate/sanitary permit – possession of valid health certificate and

sanitary permit.

5. Attendance on training/seminar on food safety education – having or not having

attended training or seminar on food safety education.

6. Food Safety – ability to maintain proper food hygiene and sanitation and

avoidance of food contamination and disease transmission

7. Food Processing – practices of food handlers in food preparation, handling,

manufacturing and storage

8. Knowledge – refers to the respondent’s understanding of food borne pathogens,

food borne diseases transmission and proper food hygiene and sanitation. A score

of 1 will be given for every correct answer, and 0 for incorrect answers. To reduce

non-response bias, “not sure” will be included. Possible scores range from 0 to 19.

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Scores will be converted to percentages. A score from 0 – 49 % will be

considered as having very poor knowledge, 50 – 74 % will be considered as

having poor knowledge and ≥ 75 will be considered as having adequate

knowledge.

9. Attitudes – refers to the respondent’s feeling/perception towards proper food

hygiene and sanitation, possibility of food contamination and consequently,

disease transmission and the need for formal training and education on food

safety. Attitudes will be evaluated using a 3 point rating scale (3 = agree, 2 =

uncertain, 1 = disagree). Possible scores range from 0 to 27. Scores will be

converted to percentages. A score from 0 – 49 % will be considered as having

very poor attitude, 50 – 74 % will be considered as having poor attitude and ≥ 75

will be considered as having good attitude.

10. Practices – refers to the respondent’s actual activities or behavior on food

handling and preparation, food manufacturing and storage and food and personal

hygiene. Practices will be evaluated using a 5 point rating scale. Possible scores

range from 1 to 105. Scores will be converted to percentages. A score from 0 – 49

% will be considered as having very poor practices, 50 – 74 % will be considered

as having poor practices and ≥ 75 will be considered as having good practices.

E. Data collection

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The fundamental tool to be use in gathering the data is the survey questionnaire.

The questionnaire is composed of well-structured statements that provided all the

necessary data about the problems presented to accomplish the objectives set by the

researchers. It is a list of planned, written questions related to a particular topic, with

spaces provided for indicating the responses to each question, instead for submission to a

number of persons for reply.

The items integrated in the questionnaire are the results of researchers’ readings

of related materials and research studies. Socio-demographic profile and practices of the

food-handlers are the main elements used for the gathering of significant data. This is

divided into four parts. The first part comprises the socio-demographic profile of the

respondents, and the second part included the practices in food sanitation, third are

questions that determine the attitude of the respondents in food sanitation and lastly the

fourth tackles the knowledge of the respondents in the food and food sanitation. The data

gathered will be tested for its reliability in accordance with the pilot testing results.

To maintain the legality and confidentiality of each involved facility, a cover

letter will be provided to explain the confidentiality of the gathered data

F. Data Processing and Data analysis

Initially, the researcher formulated a problem and will ask permission from the

Dean of School. Once proper authority and communications are already set, the

researchers will set an appointment to conduct the survey in each participants

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organization. The respondents are given a day to answer the survey tool. All retrieved

pertinent data are recorded through tallying and tabulating. The tallied and tabulated

records are addressed appropriately. The moment that all issues with the test items and

forms have been properly addressed, statistical treatment and analysis were formulated.

The data collected will be encoded using Epi info according to the coding manual.

Both descriptive and inferential statistics will be used to analyze the data collected. For

objectives one, two, three, and four descriptive analysis will be used. For objective five

and six, the chi-square test for association will be employed.

G. Survey Questionnaire

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INTRODUCTION

(Pambungad)

This survey is designed to assess your knowledge, attitudes and practices on food

preparation. All your answers will be kept confidential and will in no means be used

against you. (Ang survey na ito ay dinisenyo para alamin ang inyong kaalaman, loobin,

at gawi sa paghahanda ng pagkain. Lahat ng inyong mga tugon ay mananatiling lihim at

hindi gagamitin laban sa inyo sa kahit anong paraan.)

CONSENT (Pahintulot)

I am fully aware of the nature of this study. I have also been assured that all my

answers will be used with confidentiality and will in no means be used against me. And

as proof of my consent to this study, I will affix my signature. (Ako po ay may buong

kamalayan sa katalagahan ng pag-aaral na ito. Ako ay nabigyan ng katiyakan na lahat

ng aking mga tugon ay mananatiling lihim at hindi gagamitin sa akin sa kahit anong

paraan. Bilang katibayan ng aking pagsang-ayon sa pag-aaral na ito, ilalagay ko ang

aking lagda.)

___________________________

Signature over Printed Name

(Lagda sa taas ng nakasulat na pangalan)

Section A – Socio-demographics

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1. Name: ___________________________ 2. Gender: □ Male □ Female 3. Address: ______________________________________ 4. Age: _______5. Civil Status:

□ Single □ Separated□ Married □ Divorced□ Widowed□ Common-In-Law Union (Live-in)

6. Educational attainment:□ Elementary level □ College level□ Elementary graduate □ College graduate□ High School level □ Post-graduate□ High School graduate□ Vocational/technical

7. Religion: __________________8. Income/month (in pesos): __________9. Type of hospital: □ Government □ Private10. Length of years of employment (in years): _________11. Do you have a health certificate and/or sanitary permit? □Yes □ No12. Have you attended any trainings and/or seminars on food safety? □Yes □ NoIf yes, please specify: ______________________________________________________

Section B - Practices

Introduction: The following questions are regarding your usual practices on food preparation and vending. Please answer truthfully for there are no correct or wrong answers in each question.Pambungad: (Ang mga sumusunod pong katanungan ay tungol sa mga nakagawian ninyo sa araw-araw na pagtitinda ninyo. Sagutin nyo lamang po ng may katapatan, dahil wala naman pong tama o maling sagot sa bawat tanong.

A. Good Hygienic Practices:1. Do you wash your hands when preparing the food?

□ Always □ Often □ Sometimes □ Rarely □ Never(Naghuhugas po ba kayo ng kamay kapag naghahanda kayo ng pagkain?)

2. Do you wash your hands before distributing the food?□ Always □ Often □ Sometimes □ Rarely □ Never(Naghuhugas po ba kayo ng kamay bago kayo magdala ng pagkain sa?)

3. When preparing foods, what are the reasons for your handwashing?□ Before handling the food (Bago humawak ng pagkain) □ After handling the food (Pagkatapos humawak ng pagkain) □ After touching the money (Pagkatapos humawak ng pera)□ After handling the garbage (Pagkatapos humawak ng basura)□ After using the comfort room (Pagkataposgumamit ng palikuran)

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□ Others:______________________________

4. When washing your hands, what do you usually use?□ Water (tubig) □ Water, soap and alcohol□ Water and soap (tubig at sabon) □ Others: _____________□ Alcohol(Ano po ang ginagamit ninyo kapag naghuhugas kayo ng kamay?)

5. Do you use cloth in drying your hands?□ Always □ Often □ Sometimes □ Rarely □ Never(Gumagamit po ba kayo ng pamunasan para sa kamay ninyo?)

6. Do you use separate cloth in drying your hands and in cleaning your vending area?□ Always □ Often □ Sometimes □ Rarely □ Never(Iba po ba ang pamunasan ninyo para sa kamay at ang basahan para pamunas dito sa tindahan ninyo?)

7. Do you still sell even if you have fever?□ Always □ Often □ Sometimes □ Rarely □ Never(Nagtitinda pa rin po ba kayo kahit nilalagnat kayo?)

8. Do you still sell even if you have cough or colds?□ Always □ Often □ Sometimes □ Rarely □ Never(Nagtitnda pa rin po ba kayo kahit may ubo’t sipon kayo?)

9. Do you still sell even if you have diarrhea?□ Always □ Often □ Sometimes □ Rarely □ Never(Nagtitinda pa rin po ba kayo kahit nagtatae kayo?

B. Good Manufacturing Practices:10. Where doyou get the water you used in cooking?

□ Tap water (Gripo)□ Ground water (poso/balon) □ Others:_____________________________________(Saan po nanggagaling ang tubig na ginagamit ninyo sa pagluluto?)

11. How do you wash the raw materials?□ Thoroughly (hinuhugasang mabuti)

□ Running water (dinadaan lang sa tubig) (Paano nyo po hinuhugasan ang mga sangkap na gagamitin ninyo?)

12. Do you wash the utensils before using?□ Always □ Often □ Sometimes □ Rarely □ Never(Hinuhugasan ninyo po ba ang mga gagamitin ninyo sa pagluluto?)

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13. When washing the utensils, what do you usually use?□ Water (tubig) □ Water and soap (tubig at sabon) □ Others: _____________(Ano po ang ginagamit ninyo kapag hinuhugasan ninyo ang mga gamit ninyo sa pagluluto?)

14. Do you cover the cooked food?□ Always □ Often □ Sometimes □ Rarely □ Never(Tinatakpan niyo po ba ang niluto ninyong pagkain?)

15. Do you reuse left over foods?□ Always □ Often □ Sometimes □ Rarely □ Never(Ginagagamit niyo po ba uli ang mga natitira ninyong paninda?

16. Do you refrigerate left over foods?□ Always □ Often □ Sometimes □ Rarely □ Never(Itiniatago niyo po ba sa refrigertaor and mga natitira ninyong paninda?)

17. Do you clean your area after preparing the foods?□ Always □ Often □ Sometimes □ Rarely □ Never(Nililinis niyo po ba ang lugar ninyo pagkatapos ninyong maghanda ng

pagkain?)18. Where do you dispose your garbage?

□ Trash Can □ Sidewalks (Kalsada)□ Plastic bag □ Others:_______________

□ Sewers (kanal)(Saan niyo po tinatapon ang mga basura ninyo?)

Section C – Attitude

Introduction: The following questions are all about your attitudes towards topics related to food preparation and handling. There are no right or wrong answers. In answering, you should disregard the things you actually do. Answer according to what you really believe in. The questions should be answered with agree, uncertain or disagree. Pambungad: Ang mga sumusunod na katanungan pong ito ay patungkol sa inyong mga saloobin tungo sa paghahanda ng pagkain. Wala pong tama o maling sagot. Sa pagsagot, pansamantalang ipagsawalang-bahala ang mga aktwal na gawi. Sumagot po kayo ayon sa inyong tunay na pinaniniwalaan. Ang mga katanungan ay maaring sagutin sa pamamagitan ng sang-ayon, hindi alam, o hindi sang-ayon.

1. Safe food handling is an important part of my job responsibility.□ Agree (Sang-ayon) □ Uncertain (Hindi sigurado) □Disagree (Hindi sang-ayon)(Ang ligtas na paghahanda ng pagkain ay isa sa aking mga tungkulin na dapat bantayan.)

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2. I believe that how I handle food may be related to food safety.□ Agree (Sang-ayon) □ Uncertain (Hindi sigurado) □Disagree (Hindi sang-ayon)(Naniniwala ako na ang paraan ng paghahanda ko ng pagkain ay may kinalaman sa kaligtasan nito.)

3. Raw food should be kept separately from cooked foods.□ Agree (Sang-ayon) □ Uncertain (Hindi sigurado) □Disagree (Hindi sang-ayon)(Ang hilaw na pagkain ay dapat ihiwalay sa lutong pagkain.)

4. Defrosted foods should be refrozen only once.□ Agree (Sang-ayon) □ Uncertain (Hindi sigurado) □Disagree (Hindi sang-ayon)(Ang pagkain na nadefrost na ay maari lamang ulit ilagay sa freezer ng isang beses.)

5. Improper storage of foods may be cause of health hazard to consumers.□ Agree (Sang-ayon) □ Uncertain (Hindi sigurado) □Disagree (Hindi sang-ayon) (Ang maling paraan ng pag-imbak ng pagkain ay maaring maging sanhi ng pagkakasakit ng kostumer.)

6. Using cap, masks, gloves and adequate clothing reduce the risk of food contamination.□ Agree (Sang-ayon) □ Uncertain (Hindi sigurado) □Disagree (Hindi sang-ayon)(Ang paggamit ng cap, masks, gloves at tamang kasuotan ay nakakapagpababa ng tsansang makontamina ang pagkain.)

7. Food handlers with abrasions or cuts should not touch unwrapped food.□ Agree (Sang-ayon) □ Uncertain (Hindi sigurado) □Disagree (Hindi sang-ayon)(Ang mga taong may sugat sa kamay ay hindi dapat humawak ng pagkaing hindi nakabalot.)

8. Health examination of food handlers is important for food safety□ Agree (Sang-ayon) □ Uncertain (Hindi sigurado) □Disagree (Hindi sang-ayon) (Ang pagpapatingin sa doctor ng isang taong naghahanda ng pagkain ay mahalaga para sa kaligtasan ng pagkain.

9. Learning more about food safety is important to a food handler.□ Agree (Sang-ayon) □ Uncertain (Hindi sigurado) □Disagree (Hindi sang-ayon) (Ang patuloy na pagpapayaman ng kaalaman ukol sa kaligtasan ng pagkain y mahalaga para sa mga taong naghahanda nito.)

Section D – KnowledgeIntroduction: The following questions are all about your knowledge on topics related to food preparation and handling. There are no right or wrong answers. Do not think of what should be considered appropriate. Answer according to what you really know. The questions should be answered with yes, uncertain or no.

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(Pambungad: Ang mga sumusunod na katanungan pong ito ay patungkol sa mga bagay na inyong nalalaman tungkol sa paghahanda ng pagkain. Wala pong tama o maling sagot. Huwag po ninyong isipin kung ano ang dapat ituring na tama. Sumagot po kayo ayon sa totoo niyong nalalaman. Ang mga katanungan ay maaring sagutin sa pamamagitan ng oo, hindi alam, o hindi.)

A. Knowledge on Food borne Pathogens:1. Do you think there are microbes and/or parasites present in food?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)(Sa tingin niyo po ba ay may mga mikrobyo at parasitiko na matatagpuan sa pagkain?)

2. Do you think there are microbes and/or parasites present in water?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)(Sa tingin niyo po ba ay may mga mikrobyo at parasitiko na matatagpuan sa tubig?)

3. Do you think these microbes and/or parasites are harmful to health?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)(Sa tingin niyo po ba ang mga mikrobyo at parasitikong it ay makasasama sa kalusugan?)

4. Do you think these microbes and/or parasites are destroyed by heat?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)(Sa tingin niyo po ba ang mga mikrobyo at parasitikong it ay namamatay sa init?)

5. Do you think these microbes and/or parasites are destroyed by cold?□ □ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi) (Sa tingin niyo po ba ang mga mikrobyo at parasitikong it ay namamatay sa lamig?)

6. Do you think these microbes and/or parasites can be present in a person’s skin and/or nose?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)(Sa tingin niyo po ba ang mga mikrobyo at parasitikong ito ay matatagpuan sa balat at ilong ng isang tao?)

B. Knowledge on Food-borne diseases transmission:7. Do you think it is safe to eat food that has been exposed to pests like rats and insects like cockroaches and flies?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi) (Sa tingin niyo po ba ligtas kainin ang pagkain na dinapuan ng mga peste tulad ng daga at mga insektong tulad ipis at langaw?)

8. Do you think it is safe to eat food that has come into contact with th floor for less than one minute?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)(Sa tingin niyo po ba ligtas kainin ang pagkain na nalapat sa sahig ng kulang sa isang minuto?)

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9. Do you think hand and arm jewelries are possible sources of contamination?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi) (Sa tingin niyo po ba ang mga alahas ba sa kamay at braso ay posibleng pagmulan ng kontaminasiyon?)

10. Do you think it is okay to leave cooked food at room temperature for long hours and consume it without re-heating?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi) (Sa tingin niyo po ba ayos lang na iwan ang lutong pagkain sa loob ng mahabang oras at konsumahin ito nang hindi iniinit?)

C. Knowledge on Proper food hygiene and sanitation

Do you think it is necessary for food handlers to wash their hands with soap and water after: (Sa tingin niyo po ba kinakailangang maghugas ng kamay gamit ang sabon at tubig ang mga naghahanda ng pagkain pagkatapos:)

11. Using the toilet? (Gumamit ng banyo?)□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)

12. Sneezing or coughing, even when tissue or handkerchief was used?(Bumahing o umubo, kahit gumamit ng tissue o panyo?)□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)

13. Touching money (Humawak ng pera?)□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)

14. Do you think it is okay not to wear hair nets and aprons when handling food?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)(Sa tingin niyo po ba ayos lang na hindi magsuot ng hair net at apron kapag naghahanda ng pagkain?)

15. Do you think it is okay for a person to handle food even when he has diarrhea?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)(Sa tingin niyo po ba ayos lang na maghanda ng pagkain ang isang tao kahit siya ay nagtatae?)

16. Do you think it is okay for a person to handle food when he has open wounds on his hands?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)(Sa tingin niyo po ba ayos lang na maghanda ng pagkain ang isang tao kahit siya ay may sariwang sugat sa kanyang mga kamay?)

17. Do you think it is okay to place raw food together with cooked food during storage?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)

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(Sa tingin niyo po ba ayos lang na pagsamahin ang hilaw at lutong pagkain habang ito’y naka-imbak?) 18. Do you think it is okay to use the same, unwashed chopping boards and kitchen utensils used for preparing raw food in preparing cooked food?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)(Sa tingin niyo po ba ayos lang na gamitin ang parehong, hindi pa nahuhugasang sangkalan at mga kasangkapang pang-kusina, na ginamit sa paghahanda ng hilaw na pagkain, para sa paghahanda ng lutong pagkain?) 19. Do you think it is acceptable to continuously re-heat/ re-use left over food, sauces and dips, as long as there are no detectable changes in color, odor, or taste?□ Yes (Oo) □ Uncertain (Hindi alam) □ No (Hindi)(Sa tingin niyo po ba ayos lang na patuloy na initin/ muling gamitin ang tirang pagkain, sarsa at sawsawan, basta’t walang kapuna-punang pagbabago sa kulay, amoy at lasa nito?)

V. References

Avila, MS. 2002. Prevalence of Intestinal Helminth and Protozoan Infections among Food Handlers in Selected School Canteens in Manila using DFS and FECT. UPCPH Special Studies (unpublished).

Azanza, MPV, Gatchalian, CF, Ortega, MP. 2000. Food safety knowledge and practices of streetfood vendors in a Philippines university campus. International Journal of Food Sciences and Nutrition, 235-246.

Azanza, MPV, Gedaria AI. 1997. Hazard Analysis and control of some popular street foods in the Philippines. Terminal Report, ORC Project No. 09501-Ns.

Azanza, MPV. 2006. Philippine Foodborne Disease Outbreaks (1995-2004). Journal of Food Safety 26:92-102.

Belizario, VY., Esparar, DG, et al. 2005. Prevalence of Intestinal Parasitic Infections among Food handlers of a Tertiary Hospital in Manila using Direct Fecal Smear and Formalin Ether Concentration Technique. Phil. J Microbiol Infect Dis. 33(3):99-103.

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_______. 1996. Biotechnology & Food Safety. Report of a Joint FAO/WHO Consultation, Rome, Italy, 30 September 4 October 1996. FAO, Rome, p.4.

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

_______. 2007. Food Safety and Foodborne illness. (http://www.who.int)

_______. 2006. Health Advisory: Food Safety. (http://www.doh.gov.ph/files/food_safety).

Health surveillance and management procedures for food-handling personnel. Report of a WHO Consultation. Geneva, World Health Organization, 1989 (WHO Technical Report Series, No. 785).

Hedberg, CW and Osterholm, MT. 1993. Outbreak of Foodborne and Waterborne Gastroenteritis. Clinical Microbiology Review. 6:199.

_______. 1999. The Importance of Food Quality and Safety for Developing Countries. FAO, Rome. (http://www.fao.org/trade/docs/LDC-foodqual_en.htm).

Jacob, M.1989. Safe Food Handling: A Training Guide for Managers of Food Service Establishments. WHO. King, LK., Awumbila, B., Canacoo, EA., Ofosu-Amaah, S. 2000. An assessment of the safety of street foods in the Ga district of Ghana; implications for the spread of zoonoses. Acta Tropica 76, 39-43.

Mahon, BE., Sobel, J., Townes, JM., Mendoza, C., Gudiel Lemus, M., Cano, F., Tauxe, R.V., 1999. Surveying vendors of street-vended food: a new methodology applied in two Guatemalan cities. Epidemiol. Infect. 122, 409-416.

Mensah, P., Yeboah-Manu, D., et al. Street foods in Accra, Ghana: how safe are they?. Bulletin of the WHO. 80:546-554.

Mensah, P, Owusu-Darko, DK, et al. 1999. The role of Street food Vendors in Transmission of Enteric Pathogens. Ghana Medical Journal. 33:19-29.

Nicolas, B., Razack, BA, et al. 2007. Street-Vended Foods Improvement: Contamination Mechanisms and Application of Food Safety Objective Strategy: Critical Review. Pakistan Journal of Nutrition. 6(1):1-10.

_______. 2006 b. Procedural Manual of the Codex Alimentarius Commission. 16 th

edition. FAO, Rome.

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_______. 2007. Street foods in developing countries: lessons from Asia. FAO, Rome. (http://www.fao.org/docrep/U3550t/u3550t08.htm)

Vollaard, AM., Ali, S., Van Asten, H.A.G.H., Suhariah Ismid, I., Widjaja, S., Visser, L.G., Surjadi CH., Van Dissel, J.T. 2004. Risk factors for transmission of foodborne illness in restaurants and street vendors in Jakarta, Indonesia. . Epidemiol. Infect. 132, 863-872.

_______. 2002a. WHO Global Strategy for Food Safety: Safer Food for Better Health. WHO,Geneva.(http://www.who.int/food_safety/publication/genarl/enstrategy-en.pdf.)

Winarno, FG and Allain, A. 1986. FAO Regional Workshop on Street Foods in Asia.Zain, M.M., Naing, N.n. 2002. Sociodemographic characteristics of food handlers and their knowledge, attitude and practice towards food sanitation: a preliminary report. Southeast Asian Journal of Tropical Medicine and Hygiene 33, 410-417.

World Health Organization. 1998. Life in the 21st century. A Vision for all. The World Health Report. Geneva:WHO.

C. Administrative1. Timetable

ActivitiesMonths

1 2 3 4 5 6 7 81. Correspondence with the DOH, hospitals    2. Pretesting and Evaluation of Study Questionnaire      

3. Sampling and determination of Cluster Areas    

4. Administration of Study Questionnaire    

5. Encoding of Data from Study Questionnaire    

6. Data Processing and Analysis    

7. Preparation of Study Report    

8. Submission of Manuscript    

2. Budget

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PERSONNEL SERVICES (PS) Principal Investigator PhP 3,500 / mo x 8 mo PhP 28, 000 Consultant 1,000/mo x 8 x 1 8, 000 Data Collectors 8,000/mo x 4 x 2 64, 000

PhP 100, 000

MAINTENANCE AND OTHER OPERATING EXPENSES (MOOE)

Office supplies PhP 8, 000 Transportation 8, 000 Communication 5, 000 Photocopy 6, 000

Food (during data collection) 8, 000 Contingency 5, 000

PhP 40, 000

TOTAL PROJECTED EXPENSES PhP 140, 000

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