Journal of Food Protection, Vol. 67, No. 12, 2004, Pages 2825–2828
Hand Washing Compliance among Retail Food Establishment
Workers in Minnesota
PAUL B. ALLWOOD,1* TIMOTHY JENKINS,2COLLEEN PAULUS,1LARS JOHNSON,3AND CRAIG W. HEDBERG4
1Division of Environmental Health, Minnesota Department of Health, 121 East Seventh Place, St. Paul, Minnesota 55121;2Division of Environmental
Health, City of Minneapolis, 250 South Fourth Street, Minneapolis, Minnesota 55415;3Border Foods Incorporated, 965 Decatur Avenue North,
Golden Valley, Minnesota 55427;4Division of Environmental and Occupational Health, School of Public Health, University of Minnesota, 420
Delaware Street S.E., Minneapolis, Minnesota 55455, USA
MS 04-263: Received 16 June 2004/Accepted 30 July 2004
Inadequate hand washing by food workers is an important contributing factor to foodborne disease outbreaks in retail
food establishments (RFEs). We conducted a survey of RFEs to investigate the effect of hand washing training, availability
of hand washing facilities, and the ability of the person in charge (PIC) to describe hand washing according to the Minnesota
Food Code (food code) on workers’ ability to demonstrate food code–compliant hand washing. Only 52% of the PICs could
describe the hand washing procedure outlined in the food code, and only 48% of workers could demonstrate code-compliant
hand washing. The most common problems observed were failure to wash for 20 s and failure to use a fingernail brush. There
was a strong positive association between the PIC being a certified food manager and being able to describe the food code
hand washing procedure (odds ratio [OR], 5.5; 95% confidence interval [CI], 2.2 to 13.7), and there was an even stronger
association between the PIC being able to describe hand washing and workers being able to demonstrate code-compliant hand
washing (OR, 15; 95% CI, 6 to 37). Significant associations were detected among correct hand washing demonstration, physical
infrastructure for hand washing, and the hand washing training methods used by the establishment. However, the principal
determinant of successful hand washing demonstration was the PIC’s ability to describe proper hand washing procedure. These
results suggest that improving hand washing practices among food workers will require interventions that address PIC knowl-
edge of hand washing requirement and procedure and the development and implementation of effective hand washing training
Foodborne diseases are a major public health problem
in the United States and throughout the world (13). Noro-
viruses are the leading known cause of foodborne illness
and are increasingly recognized as the leading cause of out-
breaks (1). Infected food workers may transmit norovirus
and other foodborne pathogens by touching foods or food
contact surfaces with contaminated hands (9, 10). Accord-
ing to the Centers for Disease Control and Prevention, poor
personal hygiene is one of the five most common causes
of foodborne disease outbreaks (19). Thus, proper and con-
sistent hand washing must be practiced by all food workers
to reduce the risk of disease transmission (5, 15, 17). The
Minnesota Food Code (food code) specifies a hand washing
protocol for food workers, which includes wetting the
hands, applying soap, rubbing the hands together vigorous-
ly for at least 20 s, and rinsing with clean water (18). In
addition to this, food workers in Minnesota are required to
use a fingernail brush during hand washing to scrub areas
underneath the nails and between the fingers (18). However,
epidemiologic and inspection data show that there is low
compliance with hand washing requirements among retail
food establishment (RFE) workers (1, 19).
* Author for correspondence. Tel: 651-215-0871; Fax: 651-215-0977;
Public health agencies promote hand washing among
food workers by requiring that appropriate hand washing
facilities be provided in each RFE and that ongoing hand
washing training is conducted (18, 20). Thus, all RFEs in
Minnesota must have fully equipped hand washing stations,
and except for establishments with minimal food prepara-
tion, such as those that serve prepackaged food, all must
have a state-certified food manager who is trained in safe
food preparation, sanitation, and the prevention of food-
borne illnesses. Additionally, there must be a designated
person in charge (PIC) of a RFE at all hours of operation
who is knowledgeable about foodborne disease risk factors,
such as poor worker hygiene, and who is responsible for
ensuring that appropriate measures are in place to prevent
foodborne disease transmission.
Lack of hand washing facilities and ignorance of the
health benefits associated with hand washing are important
barriers to hand washing in the general population (6, 7,
10, 16). However, the barriers to hand washing in RFEs are
not fully understood. We therefore conducted a survey of
RFEs to investigate the relationship among hand washing
training, the ability of the PIC to describe hand washing
according to the food code, and the availability of appro-
priate hand washing facilities and workers’ ability to dem-
onstrate food code–compliant hand washing.
J. Food Prot., Vol. 67, No. 12
ALLWOOD ET AL.
FIGURE 1. Hand washing training methods used in surveyed es-
tablishments. The persons in charge were asked to select from the
following list of likely training methods: training manual, signs,
video, demonstration, explanation, training sign-off, or formal
certification. None of the establishments used all seven methods.
TABLE 2. Correct hand washing demonstrations by training
No. (%) correct
Signs and posters
aFor 37 establishments that reported using only one hand washing
training method compared with 14 establishments that did no
formal training. None of these establishments offered formal
training with certification.
TABLE 1. Correct hand washing demonstrations by training methods useda
Training method Frequency (%)b
No. (%) correct hand washing
Signs and posters
aFor all establishments.
bFifty-three percent of establishments reported using two or more training methods.
MATERIALS AND METHODS
Data were collected by sanitarians while conducting routine
inspections of 123 RFEs. The surveyed establishments included
restaurants, delis, bakeries, and grocery stores in 12 inspectional
jurisdictions across Minnesota. A standardized instrument was
used to collect data for the study, and all participating sanitarians
were trained to use the instrument before data collection began.
In each establishment surveyed, the PIC was asked if he or she
was a state certified food manager. Then the PIC was asked to
describe the hand washing procedure stipulated by the food code
and to identify which if any of the following methods were used
to conduct employee hand washing training: posted materials,
training video, use of written training manual, explanation of hand
washing requirement and procedure, demonstration of proper hand
washing, training with employee sign-off, and/or comprehensive
training with formal certification. After the PIC was interviewed,
a food handler was asked to demonstrate hand washing according
to the food code. Care was taken to select a worker who had not
heard the hand washing description given by the PIC. A satisfac-
tory hand washing description or demonstration had to include
wetting the hands, lathering soap up to the wrist, rubbing vigor-
ously for 20 s, using a fingernail brush, rinsing with clean water,
and drying hands with a disposable paper towel. Following the
demonstration, the evaluator conducted an inspection of the es-
tablishment’s hand washing facilities to determine if they were
accessible, supplied with water at a temperature of at least 43?C
(110?F), and clean and if soap, disposable towels, and a fingernail
brush were present at the sink. Inspection of the hand washing
facilities was performed after the hand washing demonstration to
reduce the likelihood of bias.
Statistical analysis of the data was performed with the Sta-
tistical Analysis System (SAS) software (SAS Institute, Cary,
N.C.) and EpiInfo 2002 (Centers for Disease Control and Preven-
tion, Atlanta, Ga.). The analysis of variance procedure was used
to test associations among numerical variables, and associations
among categorical variables were tested by ?2tests.
Training methods. Most establishments provided some
type of hand washing training to employees. The number
of methods used for hand washing training ranged from no
formal training in 14% of the establishments to six different
methods in one establishment (Fig. 1). The most frequently
reported method used for hand washing training was a ver-
bal explanation of hand washing (Table 1). Among estab-
lishments that used only one method of training, demon-
stration and explanation were the most effective methods
in that employees in RFEs that reported using either of
these methods were two to three times more likely to dem-
onstrate code-compliant hand washing than were employees
who received no formal training (Table 2). However, the
effectiveness of all training methods was dependent on the
J. Food Prot., Vol. 67, No. 12HAND WASHING AMONG FOOD WORKERS
FIGURE 2. Percentage of correct hand washing demonstrations
by number of training methods. The training methods were train-
ing manual, signs, video, demonstration, explanation, training
sign-off, or formal certification. None of the establishments used
all seven methods.
PIC’s ability to describe hand washing, and irrespective of
the training method, 60 to 84% of workers could demon-
strate hand washing when the PIC could describe hand
washing and only 0 to 30% of workers could when the PIC
could not describe the procedure. There was also a strong
positive association between the number of hand washing
training methods and worker’s ability to demonstrate hand
washing (?2test for trend, P ? 0.01) (Fig. 2).
Hand washing description. Only 52% of the PICs
could describe the hand washing procedure outlined in the
food code. The PICs who were state-certified food man-
agers were more likely to be able to describe the food code
hand washing procedure (48 [66%] of 73 compared with 8
[25%] of 32; odds ratio [OR], 5.8; 95% confidence interval
[CI], 2.3 to 14.7). Failure to specify the need to use a fin-
gernail brush was the most common problem with the hand
washing descriptions given by the PICs. However, 77% of
PICs who were state certified food managers described the
need to use a fingernail brush compared with 38% of un-
certified PICs (OR, 5.5; 95% CI, 2.2 to 13.7).
Hand washing demonstration. Only 48% of food
handlers could demonstrate hand washing according to the
food code. The most frequent problems with the hand
washing demonstrations were failure to use a fingernail
brush and failure to wash for 20 s. These problems were
noted in 89 and 60% of incorrect hand washing demon-
strations, respectively. The ability to demonstrate code-
compliant hand washing was significantly associated with
the PIC being able to describe hand washing (44 [76%] of
58 compared with 9 [18%] of 51; OR, 14.7; 95% CI, 5.7
Hand washing facilities. Only 68 (55%) of the estab-
lishments surveyed were fully equipped for hand washing
according to the food code. The most common problems
with the hand washing facilities were a lack of fingernail
brush and inaccessibility of the hand sink. These problems
were noted in 38 and 24% of the establishments, respec-
tively. Hand washing facilities were more likely to be fully
equipped in the establishments where a certified food man-
ager was the PIC during the survey (45 [60%] of 75 versus
12 [38%] of 32; OR, 2.5; 95% CI, 1.1 to 6.3). A nailbrush
was at the demonstration sink in 62% of establishments,
elsewhere in the establishment in 21%, and completely ab-
sent in 17% of establishments. If the brush was at the sink
it was used 86% (57 of 66) of the time, whereas if it was
not at the sink it was used 7% (3 of 44) of the time (OR,
87; 95% CI, 22 to 339).
Poor hand washing by food workers is an important
risk factor for foodborne disease outbreaks in RFEs (3, 7,
11, 14, 21). This includes the failure to both wash hands
and wash hands correctly. Although we were not able to
directly observe the frequency or adequacy of hand wash-
ing during routine foodservice operations, we believe that
being able to demonstrate proper hand washing technique
is a necessary condition for good hand washing practices
and may be a useful indicator of likely hand washing com-
pliance in RFEs (13, 17).
Several important findings were made in this study.
Among them, we have shown that there is a strong asso-
ciation between the hand washing knowledge of the PIC
and the ability of food workers to demonstrate proper hand
washing. Assigning a person who is knowledgeable about
operational and code requirements to be in charge of a RFE
at all hours of operation is essential for ensuring the appro-
priate detection and resolution of food safety hazards (4).
However, under current Minnesota food regulations, a PIC
of a food establishment does not have to demonstrate
achievement of food safety knowledge standards through
testing and certification; thus, the food safety knowledge of
individual PICs is highly variable. These results suggest
that uncertified managers may lack the skills and/or incli-
nation to ensure appropriate levels of compliance with hand
washing by food workers; thus, a certified food manager
may need to be present in high-risk RFEs during all hours
of operation to help ensure acceptable levels of hand wash-
Workers in establishments that conduct some type of
hand washing training could more frequently demonstrate
proper hand washing than workers in establishments that
did no training. In addition, hand washing performance was
directly proportional to the number of methods used to con-
duct hand washing training. These findings reinforce the
long-held belief that appropriate food safety education can
help improve food safety performance in retail establish-
ments (2, 4, 12). In particular, demonstration of hand wash-
ing technique and verbal explanations of hand washing ap-
peared to be the most effective training methods when used
alone. Both depend on personal communication with the
food worker. In contrast, less personal methods, such as the
use of training manuals, signs, posters, and videos, did not
appear to be successful when used as the sole method.
However, these materials may be important to reinforce the
primary training. The increasing effectiveness of multiple
methods of training also suggests that repeating the training
messages in different ways may be important (8).
J. Food Prot., Vol. 67, No. 12 Download full-text
ALLWOOD ET AL.
In conclusion, our results suggest that improving
hand washing practices among food workers will require
interventions that address PIC knowledge of hand wash-
ing requirement and procedure, physical facilities for
hand washing, and the development and implementation
of appropriate training methods. Personal communication
with the food worker appears to be important for effective
training and is very likely to be important for translating
hand washing knowledge into routine practice.
1.Bean, N. H., J. S. Goulding, C. Lao, and F. J. Angulo. 1996. Sur-
veillance for foodborne-disease outbreaks—United States, 1988–
1992. MMWR CDC Surveill. Summ. 45:1–66.
Campbell, M. E., C. E. Gardner, J. J. Dwyer, S. M. Isaacs, P. D.
Krueger, and J. Y. Ying. 1998. Effectiveness of public health inter-
ventions in food safety: a systematic review. Can. J. Public Health
Clayton, D. A., C. J. Griffith, P. Price, and A. C. Peters. 2002. Food
handlers’ beliefs and self-reported practices. Int. J. Environ. Health
Cotterchio, M., J. Gunn, T. Coffill, P. Tormey, and M. A. Barry.
1998. Effect of a manager training program on sanitary conditions
in restaurants. Public Health Rep. 113:353–358.
Curtis, V., and S. Cairncross. 2003. Effect of washing hands with
soap on diarrhoea risk in the community: a systematic review. Lancet
Infect. Dis. 3:275–281.
Drankiewicz, D., and L. Dundes. 2003. Hand washing among female
college students. Am. J. Infect. Control 31:67–71.
Duse, A. G., M. P. da Silva, and I. Zietsman. 2003. Coping with
hygiene in South Africa, a water scarce country. Int. J. Environ.
Health Res. 13(Suppl. 1):S95–105.
Ebel, B. E., T. D. Koepsell, E. E. Bennett, and F. P. Rivara. 2003.
Use of child booster seats in motor vehicles following a community
campaign: a controlled trial. JAMA 289:879–884.
Guinan, M. E., M. McGuckin-Guinan, and A. Sevareid. 1997. Who
washes hands after using the bathroom? Am. J. Infect. Control 25:
Hoque, B. A., D. Mahalanabis, M. J. Alam, and M. S. Islam. 1995.
Post-defecation hand washing in Bangladesh: practice and efficiency
perspectives. Public Health 109:15–24.
Jones, T. F., B. I. Pavlin, B. J. LaFleur, L. A. Ingram, and D. W.
Schaffner. 2004. Restaurant inspection scores and foodborne disease.
htm. Accessed March 2004.
Mathias, R. G., R. Sizto, A. Hazlewood, and W. Cocksedge. 1995.
The effects of inspection frequency and food handler education on
restaurant inspection violations. Can. J. Public Health 86:46–50.
Mead, P. S., L. Slutsker, V. Dietz, L. F. McCaig, J. S. Bresee, C.
Shapiro, P. M. Griffin, and R. V. Tauxe. 1999. Food-related illness
and death in the United States. Emerg. Infect. Dis. 5:607–625.
Oteri, T., and E. E. Ekanem. 1989. Food hygiene behaviour among
hospital food handlers. Public Health 103:153–159.
Sattar, S. A., V. S. Springthorpe, J. Tetro, R. Vashon, and B. Kes-
wick. 2002. Hygienic hand antiseptics: should they not have activity
and label claims against viruses? Am. J. Infect. Control. 30:355–372.
Sharek, P. J., W. E. Benitz, N. J. Abel, M. J. Freeburn, M. L. Mayer,
and D. A. Bergman. 2002. Effect of an evidence-based hand washing
policy on hand washing rates and false-positive coagulase negative
staphylococcus blood and cerebrospinal fluid culture rates in a level
III NICU. J. Perinatol. 22:137–143.
Sobel, J., B. Mahon, C. E. Mendoza, D. Passaro, F. Cano, K. Baier,
F. Racioppi, L. Hutwagner, and E. Mintz. 1998. Reduction of fecal
contamination of street-vended beverages in Guatemala by a simple
system for water purification and storage, hand washing, and bev-
erage storage. Am. J. Trop. Med. Hyg. 59:380–387.
State of Minnesota. 1998. Minnesota Food Code. State of Minnesota,
U.S. Food and Drug Administration. 2000. Report of the FDA retail
food program database of foodborne illness risk factors. Available
at: http://www.cfsan.fda.gov. Accessed January 2004.
U.S. Public Health Service. 2001. FDA food code. Food and Drug
Administration, Washington, D.C.
Weinstein, J., T. Oteri, and E. E. Ekanem. 1991. The clean restaurant,
II: employee hygiene. Restaurants Inst. 101:138–139, 142, 144 pas-