The evaluation of food hygiene knowledge, attitudes, and practices
of food handlers? in food businesses in Turkey
Murat Bas ?*, Azmi S ?afak Ersun, Go ¨khan Kıvanc ¸
Health Sciences Faculty, Department of Nutrition and Dietetics, Baskent University, Bag ˘lica Kampu ¨su ¨, Eskis ?ehir Yolu 20.km, Ankara 06530, Turkey
Received 22 June 2004; received in revised form 9 November 2004; accepted 11 November 2004
The purpose of this study was to evaluate knowledge, attitudes, and practices concerning food safety issues among food handlers
in Turkey, conducting face to face interview and administrating questionnaire. Of the 764 food handlers who responded, 9.6% were
involved in touching or distributing unwrapped foods routinely and use protective gloves during their working activity. A majority
of participants (47.8%) had not taken a basic food safety training. The mean food safety knowledge scores was 43.4 ± 16.3. The
study demonstrated that food handlers in Turkish food businesses often have lack of knowledge regarding the basic food hygiene
(critical temperatures of hot or cold ready-to-eat foods, acceptable refrigerator temperature ranges, and cross-contamination etc.).
There is a immediate need for education and increasing awareness among food handlers regarding safe food handling practices.
? 2004 Elsevier Ltd. All rights reserved.
Keywords: Food handlers; Food businesses; Knowledge; Attitudes
The increasing number of food poisoning outbreaks
and food-related scares has led to calls for better hygiene
and quality practices. Food poisoning outbreaks of sal-
monella, listeria, and Escherichia coli 0157 have made
the public more sceptical of the food they consume. In
recent months the debate surrounding The European
Commission has recognized the importance of control-
ling food-poisoning outbreaks owing to the increasing
number of meals consumed outside the home, in parallel
with the everexpanding range of pre-prepared meals.
This changing consumer lifestyle emphasizes the need
for better, effective ways of controlling food hygiene.
There is strong statistical evidence that the incidence
of food poisoning caused by caterers is greater than in
any other food sector, accounting for 70% of all bacte-
rial food poisoning outbreaks. Seventy per cent of these
food poisoning outbreaks are due to the inadequate time
and temperature control of food, while the remaining
30% are the result of cross-contamination (Wilson,
Murray, Black, & McDowell, 1997).
The hands of food service employees can be vectors in
the spread of foodborne diseases because of poor per-
sonal hygiene or cross-contamination. For example, an
employee might contaminate his hands when using the
toilet, or bacteria might be spread from raw meat to sal-
ad greens by food handler?s hands, point out that data
on risk factors for foodborne diseases imply that most
outbreaks result from improper food handling practices
(Ehiri & Morris, 1996). A study in the USA suggested
that improper food handler practices contributed
to approximately 97% of foodborne illnesses in food-
service establishments and homes (Howes, McEwen,
Griffiths, & Harris, 1996).
Food poisoning follows the ingestion of microorgan-
isms that may have been present in already contami-
nated food, which may have resulted from inadequate
0956-7135/$ - see front matter ? 2004 Elsevier Ltd. All rights reserved.
*Corresponding author. Tel.: +90 312 2341010/1605/1606; fax: +90
E-mail address: email@example.com (M. Bas ?).
Food Control 17 (2006) 317–322
food preservation techniques or unsafe handling prac-
tices or which may have arisen from cross-contamina-
tion from surfaces, equipment, or, less likely, from
persons who carry enterotoxigenic staphylococci in their
nares or on their skin (Barrie, 1996; Jay, Comar, &
Govenlock, 1999). Similarly, infected food handlers
are also a common source of foodborne viruses such
as the Hepatitis A virus and the diarrhoea-causing,
small round-structured viruses which are excreted in
large numbers by infected individuals. Many cases of
foodborne virus infection have been associated with
catering (WHO, 1999). Poor sanitary practices in food
storage, handling, and preparation can create an envi-
ronment in which bacteria such as camphylobacter, sal-
monella, and other infectious agents are more easily
transmitted (Fielding, Aguirre, & Palaiologos, 2001;
Gent, Telford, & Syed, 1999).
Food handlers may transmit pathogens passively
from a contaminated source, for example, from raw
poultry to a food such as cold cooked meat that is to
be eaten without further heating. They may also, how-
ever, themselves to be sources of organisms either during
the course of gastrointestinal illness or during and after
convalescence, when they no longer have symptoms.
During the acute stages of gastroenteritis large number
of organisms are excreted and by the nature of the dis-
ease are likely to be widely dispersed; clearly, food hand-
lers who are symptomatically ill may present a real
hazard and should be excluded from work. Good hy-
giene, both personal and in food handling practices, is
the basis for preventing the transmission of pathogens
from food handling personnel to consumer. (Bryan,
1988; Evans et al., 1998). The Food and Drug Adminis-
tration (FDA), with support from enforcement agencies
and the food industry has endorsed food service worker
training since 1976; however, since that time, the retail
food service industry, has intensified efforts to improve
retail food safety through training of restaurant mana-
gers and employees (Lynch, Elledge, Griffith, & Boatrigh,
2003). When food poisoning outbreaks are investigated
it has been established that small and medium sized
businesses are often important locations in the transmis-
sion of foodborne illness (Walker, Pritchard, & Forsy-
In Turkey, there are many issues imposing risk on
food safety due to industrialization and mass produc-
tion, emergence of longer and more complex food
chains, fast food consumption, street vendors and grow-
ing international trade and tourism. Besides, long-term
inflation and other economical causes; advertisements,
growing eating out habits (fast foods, restaurant meals
etc.) are also the likely causes of food safety problems
in Turkey. The purpose of this study was to evaluate
knowledge, attitudes, and practices among food han-
dlers with regard to food hygiene in food businesses in
Ankara, the capital city of Turkey.
2. Material and methods
2.1. Participating businesses
This survey was conducted from November 2003 to
May 2004 involving 764 food handlers in 109 food busi-
nesses in Ankara, Turkey. Assessments were comprised
of hospital food services (31), catering establishments
(14), school food services (4), hotels (11), kebab houses
(27), takeaways (14) and restaurants (18). A written
two questionnaires were prepared for this study. All
questionnaires were followed by a face-to-face interview
regarding the questions and responses to ensure the
accuracy of the responses. Ten interviewers in research
team were trained by the researchers to conduct assess-
ments. The interviewers who were selected had educa-
tional backrounds in nutrition and dietetics. The
interview was conducted by the research team members
who read each of the questions aloud during interview.
Respondents were given adequate time to answer each
query in writing.
2.2. Food safety knowledge questionnaire
The food safety knowledge questionnaire was de-
signed to obtain information about food handlers
knowledge of food poisoning, personal hygiene, cross-
contamination, high-risk food groups, cleaning and,
temperature control. The questionnaire for food hand-
lers included 24 questions each with five possible ans-
wers. To reduce the response bias, the multiple choice
answers included ‘‘not sure’’. In addition, 9 questions
were related with demographic characteristics of food-
service staff (education level, age, gender, number of
years staff in foodservice operations, food safety train-
ing). The score range was between 0 and 24. The scores
were converted to 100 points. The score below 50% of
food safety knowledge questionnaire is accepted as poor
2.3. Food safety attitudes and practices questionnaire
The questionnaire was prepared based on the previ-
ous research conducted by Angelillo, Viggiani, Greco,
and Rito (2001). Part I included 10 questions related
to food handler attitudes toward food safety. Food
handlers were asked to indicate their level of agreement
to the statements using a three-point rating scale (3 =
agree, 2 = uncertain and, 1 = disagree). The score range
was between 0 and 30. The scores were converted to 100
points. Part II of the questionnaire consisted of a list of
10 practices that would indicated food handlers? prac-
tices toward foodborne disease prevention. A five-point
rating scale (1 = never to 5 = always) was used for
respondents to rate the level of impact of each practice.
M. Bas ? et al. / Food Control 17 (2006) 317–322
The score range was between 0 and 50. The scores were
converted to 100 points.
2.4. Pilot test
The reliability of food safety knowledge question-
naire was also determined by pilot study on 50 food-ser-
vice staff. The reability coefficient of knowledge test was
0.74. As a result of the item analysis, several test ques-
tions were modified to improve clarity.
2.5. Statistical analysis
All statistical analyses were conducted using SPSS for
Windows (version 11.0, 2001, Chicago, IL). Statistical
significance was set p < 0.05. The differences between
training and untraining food handlers mean values was
determined by a parametric (independent sample t-test)
Seven hundred and sixty-four of the 796 food service
staff replied to the questionnaire from 109 food busi-
nesses, with a response rate of 95.9%. The majority
(46.6%) of the food handlers had some primary educa-
tion (year 5 of primary school) degree. Approximately
half (51.3%) of the participants had been employed 10
or more years in some segment of the food businesses.
The major group (46.7%) of the food handlers were be-
tween 31 and 50 years of age, and 22.5% were females.
3.2. Food safety knowledge
The food safety knowledge of food handlers were
poor (Fig. 1). A majority of participants (47.8%) had
not taken a food safety training. The mean food safety
knowledge scores was 43.4 ± 16.3 (100 possible points).
Mean scores and standard deviations for questionnaire
sections were as follows: knowledge of temperature con-
trol (45.5 ± 30.7), knowledge of food poisoning (42.7 ±
19.4), knowledge of cross-contamination (53.4 ± 19.2)
and, knowledge of personal hygiene (31.8 ± 23.1). Food
safety knowledge questions that were most frequently
answered incorrectly were related to time–temperature
control and cooling and thawing and hand-washing
practices. Total score of food safety knowledge ques-
tionnaire was higher in trained food handlers (45.8 ±
(p < 0.05). In addition, results indicated that total food
safety knowledge scores are higher in food handlers
in the hospital food services (42.8 ± 12.1) and school
food services (58.4 ± 15.8) than catering establishments
handlers (40.8 ± 14.3)
(41.2 ± 11.3), restaurants (26.8 ± 9.1), hotels (38.2 ±
12.1),kebab houses (37.8 ± 13.2)
(37.5 ± 15.9) (p < 0.05).
3.3. Food safety attitudes
Table 1 shows the attitudes of food handlers toward
the prevention and control of foodborne diseases. A po-
sitive attitude was reported by a great majority of food
handlers, who agreed that using cap, masks, protective
gloves and adequate clothing reduces the risk of food
contamination (82.9%). Food handlers believe that
how they handle food relates to food safety (81.7%),
and improper storage of foods may be a hazardous to
health (78.7%). Findings showed that personal with
abrasions or cuts in fingers or hands should not touch
unwrapped foods (do not cover cuts with easily detect-
able plasters) (45.8%), and that raw foods should be iso-
lated from cooked foods (59.3%). In addition, the food
safety attitudes scores of food handlers was 44.2 ± 13.2
(100 possible points) (Fig. 1), and there is no difference
in attitudes scores between training and untraining food
handlers (p > 0.05). The food safety attitudes scores
was higher in food handlers in catering establishments
(47.1 ± 15.9), school food services (40.8 ± 9.4) and
hospital food services (46.2 ± 14.3) than restaurants
(38.1 ± 9.6), hotels (37.9 ± 5.2), kebab houses (34.1 ±
6.3) and takeaways (39.6 ± 5.4) (p < 0.05).
3.4. Food safety practices
The self-reported hygienic practices showed that only
9.6% of those who involved in touching or distributing
unwrapped foods routinely (always) use protective
gloves during their working activity (Table 2). Of those
food handlers who used gloves, most washed their hands
before putting them on (8.1%) and after removing them
(3.8%). Therefore, the practice score of food handlers
Knowledge of temperature control
Knowledge of food poisoning
Knowledge of cross-contamination
Knowledge of personal hygiene
Total Food Safety Knowledge Score
Food Safety Practice Score
Food Safety Attitudes Score
Fig. 1. Food safety knowledge scores, practices scores and attitudes
scores of food handlers in food businesses
M. Bas ? et al. / Food Control 17 (2006) 317–322
were 48.4 ± 8.8 (100 possible points) (Fig. 1). In addi-
tion, there is a difference in food safety practices scores
between trained and untrained food handlers (p < 0.05).
Results showed that food safety practice scores was
(50.4 ± 9.4), school food services (52.5 ± 9.2) and hospi-
tal food services (50.9 ± 9.2) than restaurants (47.3 ±
8.6), hotels (47.4 ± 8.3), kebab houses (37.9 ± 6.7) and
takeaways (44.1 ± 2.5) (p < 0.05).
The limited research related to food safety knowl-
edge, practices, and attitudes of food handlers in food
businesses indicates food-handling problems need to
be addressed. Ehiri and Morris (1996) pointed out that
data on risk factors for foodborne diseases imply that
most outbreaks result from improper food handling
practices. A study in USA suggested that improper food
handling practices contributed to approximately 97% of
foodborne illnesses in food-service establishments and
homes (Howes et al., 1996). Consequently, in order to
reduce foodborne illnesses it is crucial to gain an under-
standing of the interaction of prevailing food safety
beliefs, knowledge and practices of food handlers
(WHO, 2000). However, the efficacy of current food
hygiene training is uncertain. A number of studies
(Howes et al., 1996; Powell, Attwell, & Massey, 1997)
have indicated that although training may bring about
an increased knowledge of food safety this does not
always result in a positive change in food handling
behaviour. It has been suggested that this disparity be-
tween knowledge and practice occurs because much of
the existing training, particularly formal certificated
training, is designed using the KAP model (Rennie,
1995). This approach assumes that an individual?s
behaviour or practice (P) is dependent on their know-
ledge (K) and suggests that the mere provision of infor-
mation will lead directly to a change in attitude (A) and
consequently a change in behaviour. It has been sug-
gested that this model is flawed in its assumption that
knowledge is the main precursor to behavioural change
(Ehiri, Morris, & McEwen, 1997).
Recently, Turkish Food Code changes mean that all
Turkish food businesses must now provide food hygiene
training commensurate with the work activities of their
staff (Sag ˇlam, 2000). However, the findings of this study
indicated that 47.8% of basic food handlers have not re-
ceived basic food hygiene training. In a study, 55% of
Food handlers? attitudes about food safety (n = 764)
StatementsAgree (%) Uncertain (%)Disagree (%)
Safe food handling is an important part of my job responsibilities
Learning more about food safety is important to me
I believe that how I handle food relates to food safety
Raw foods should be kept separately from cooked foods
Defrosted foods may be refrozen only once
Using cap, masks, protective gloves, and adequate clothing reduces
the risk of food contamination
It is important to know the temperature of the refrigerator to reduce the risk of food safety
It is necessary to check thermometer settings of refrigerators and freezers once per day
Improper storage of foods may be hazardous to health
Food-services staff with abrasion or cuts on fingers or hands should not
touch unwrapped foods (do not cover cuts with easily detectable plasters)
Food handlers? practices toward food-borne disease prevention (n = 764)
Do you use gloves when you touch or distribute unwrapped foods?
Do you wash your hands before using gloves?
Do you wash your hands after using gloves?
Do you use protective clothing when you touch or distribute unwrapped foods?
Do you use a mask when you touch or distribute unwrapped foods?
Do you wear a cap when you touch or distribute unwrapped foods?
Do you wash your hands before touching unwrapped raw foods?
Do you wash your hands after touching unwrapped raw foods?
Do you wash your hands before touching unwrapped cooked foods?
Do you wash your hands after touching unwrapped cooked foods?
M. Bas ? et al. / Food Control 17 (2006) 317–322
the 444 food handlers surveyed had undertaken formal
food hygiene training, and 63% of managers had under-
taken formal food hygiene training in UK food busi-
nesses (Walker, Pritchard, & Forsythe, 2003b).
The hands of food service staff can be vectors in the
spread of foodborne diseases because of poor personal
hygiene or cross-contamination. For example, a staff
might contaminate his hands during using the toilet,
or bacteria might be spread from raw meat to salad
greens by food handler?s hands (Fuerst, 1983). In our
study, the food handlers always need to wash their
hands, after touching unwrapped raw foods (2.2%), be-
fore touching unwrapped cooked foods (5.0%), and
after touching unwrapped cooked foods (5.5%) (Table
2). In addition, knowledge of personal hygiene scores
were poor (31.8 ± 23.1) (Fig. 1). The results indicate that
food handlers in food businesses may have lack of
knowledge about food safety. For example, only
21.2% of food handlers identified the need to wash their
hands after going to the toilet, handling raw foods and
before handling ready-to-eat food in our study (no
Attitudes, an important factor besides knowledge and
enforcement, ensure a downward trend of foodborne ill-
nesses. The necessary link of positive behaviour, atti-
tudes and continued education of food handlers
towards the sustainability of safe food handling prac-
tices has been highlighted (Howes et al., 1996). A gener-
ally negative attitude toward correct handling of food,
safe storage practices, and cross-contamination control
was to be found among food handlers. Therefore, the
attitude scores toward foodborne diseases prevention
and control was poor (44.2 ± 13.2). Similarly, the food
safety practice scores of food handlers were very low
(48.4 ± 8.8) (Fig. 1).
Foods vary in composition, so no single cooking tem-
perature is going to give the culinary quality desired and
the safety needed for all food; there are various combi-
nations of time and temperatures needed to inactivate
pathogenic vegetative bacteria (Schmidt & Rodrick,
2003). Since temperature treatment is frequently the crit-
ical control point a production process, the issue of poor
temperature understanding could be a major hindrance
of effective HACCP implementation (Walker et al.,
2003b). In this study, there was lack of knowledge
among the food handlers about the critical temperatures
of hot or cold ready-to-eat foods, acceptable refrigerator
temperature ranges, and cross-contamination. Only
42.0% of food handlers knew the correct temperature
for holding hot food (63 ?C) In addition, 18.3% of food
handlers correctly answered cooked rice as a high risk
food (no data). In a previous study (Walker et al.,
2003b); less than half of 444 food handlers knew the cor-
rect temperature food holding hot food. Both studies
showed lack of knowledge of critical temperature of
As a conclusion, the findings of this study demon-
strated that food handlers in food businesses have lack
of food safety knowledge. Therefore substantive food
safety training should be provided for all food-service
staff before they begin to work continuous food safety
training as well.
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