Study design and area
A descriptive cross-sectional study was employed to assess the determinants of hand hygiene practices at critical times among educational institutions food handlers in the Sagnarigu Municipality. The Municipality has a population of 148,099 with males constituting about 50.6 per cent of the people. The economy of the Municipality is mainly agriculture and commerce-based.38 The Municipality has a total of 122 primary schools, 57 Junior High schools, and 4 Senior High schools. The Municipality is home to several tertiary institutions such as Tamale Technical University, Tamale College of Education, Bagabaga College of Education, Tamale School of Hygiene, Tamale Community Health Nursing, Workers College, and Graduate School of the University for Development Studies.39
Sample size and Sampling
Through convenience sampling, the researchers approached the food handlers in the educational institutions and invited them to participate in the study. It means the total number (302) of readily available food handlers across the educational institutions were invited to participate in the study at the time of our visit to the schools. All food handlers who agreed to participate in the study were therefore interviewed giving rise to the sample size of two hundred and six (206) food handlers. At the tertiary level, only Tamale Technical University and Graduate School of the University for Development Studies were in session, making them the only tertiary institutions that qualified for their food handlers to participate in the study. However, the Graduate School of the University for Development Studies were excluded because there was no stationery food handler in the campus of the graduate school.
The study included only stationery food handlers while mobile food handlers and government-employed institutional food handlers for boarding schools were excluded from the study. Educational institutions that were on break were eliminated from the survey since the food handlers only report to work on the resumption of the students.
Data collection
The tool for the data collection tool was adapted from two similarly published studies conducted in Ethiopia and Malaysia 40, 41 and modified to suit food handlers. The study tool was further validated by a Committee on Human Research, Publication and Ethics of the Kwame Nkrumah University of Science and Technology. The questionnaire was administered using the interviewer assisted questionnaire administration. Two graduating students of the Higher National Diploma in hospitality and tourism management were recruited to collect the data. The data collectors were trained on the data collection tool, objectives of the study, how to select the respondents, how to ensure confidentiality and ethics in the field. The data collection process was supervised by the principal investigator. Each questionnaire was reviewed for completeness, quality, and consistency on each day of the data collection period. The questionnaire consisted of 5 parts: section A, sociodemographic information and training on hand hygiene (18 questions); Section B, knowledge about hand hygiene at critical times (32 items); section C, hand hygiene attitudes (18 statements); section D, hand hygiene practices at critical times (14 questions) and section E, observation checklist (11 items).
Study variables
Outcome variables
The two main outcome variables were good hand hygiene and poor hand hygiene practice at critical times. Food handlers hand hygiene practices at critical times were measured by asking 14 practice questions which pertained to whether the food handlers always washed their hands with water and soap after sneezing and coughing, after visiting the toilet, after handling raw food such as meat, before starting to sell food, after touching body parts, before/after eating, before preparing food, before handling cooked food, after touching money, after cleaning a child’s bottom, after cleaning duties, after picking something on the floor, after handling waste/garbage and after touching animals. A correct response, "yes" was coded as 1 and a "no" or "can't remember" responses were coded as 0. A mean value was calculated and those food handlers who scored above the mean value were considered as good hand hygiene practice at critical times otherwise were considered as poor hand hygiene practice.
Independent variables
The independent variables for this study were age, marital status (married, not married), religious affiliation (Christianity, Islam, others), level of education (No formal education, basic education, secondary education, tertiary education), family size (the number of people at their household), number of years of selling food (the number of years selling food in the school), training on food safety (yes, no), handwashing education (yes, no), heard about handwashing at critical times (yes, no), the sufficiency of water for handwashing in the school (yes, no), the water source for selling food (in the school, from home, others), source of information on handwashing (health workers, television, teachers, family members, other sources), type of water source (tap water, tank storage, borehole, others), materials always used in handwashing (water only, water and soap), knowledge of hand hygiene at critical times, and attitude towards hand hygiene at critical times.
Knowledge of hand hygiene: Food handlers were asked 32 knowledge items with most of the questions consisting of three responses i. e. "yes", "no" and "I don’t know" The knowledge questions sought to find out whether the food handlers knew hand hygiene practices at critical times, whether they knew the importance of handwashing at critical times during food handling, whether the food handlers knew handwashing at critical times will reduce food contamination, whether they knew handwashing at critical times will reduce foodborne diseases, diseases contracted by not washing hands at critical times, whether the respondent knew dirty and long finger nails could contaminate food with a disease-causing microorganism, whether the food handler knew improper hand washing can transmit microorganisms to food, whether they knew foodborne diseases can be controlled by proper hand washing, whether they knew bacteria are found on the surfaces of human skin, raw food may contain harmful bacteria that can contaminate RTE food, whether the food handler knew it is important to wash hands after handling garbage/waste, after handling money, after sneezing and coughing on hands, before preparing food, before starting to sell food, after cleaning the child's bottom, after visiting the toilet, after handling raw food and after cleaning or sweeping the environment. A correct response was coded as “1” and a wrong response or "I don't know" was coded as “0”. A mean value was calculated and those food handlers who scored above the mean value were considered as having sufficient knowledge whereas those who scored below the mean mark were considered as having insufficient knowledge.
Food handlers attitudes towards hand hygiene: To measure food handlers’ attitudes towards hand hygiene practices at critical times, they were asked to indicate their level of agreement to 19 statements with three possible options: "agree", "disagree" and "not sure". A positive response, "agree" were coded as “1” and a negative response, "disagree" or "not sure" were coded as “0”. One of the statement was negatively worded and hence, the score was reversed. A mean value was calculated and those food handlers who scored above the mean value were considered as having a positive attitude towards hand hygiene at critical times otherwise were considered as having a negative attitude.
Data analysis
Data analysis was performed using STATA 14.2. Statistical significance was set at a level of p<0.05. Descriptive statistics were first used to present respondents' sociodemographic and other WASH-related information, knowledge of hand hygiene at critical times, attitudes towards hand hygiene, hand hygiene practice at critical times, and observation of hand hygiene practices in text, tables, and figures. To identify the determinants of hand hygiene practices at critical times, a logistic regression analysis was done to determine the association between food handlers' sociodemographic information, WASH-related information, knowledge of hand hygiene, attitudes towards hand hygiene and hand hygiene practice at critical times. Variables that were significant after the bivariate logistic regression analysis were included in the multivariate logistic regression analysis to determine the strength of association using their computed crude and adjusted odds ratios and respective 95% confidence intervals.