Food Control 34 (2013) 662e667

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Food Control
journal homepage: www.elsevier.com/locate/foodcont

Improvement of food safety in school meal service during a long-term

intervention period: a strategy based on the knowledge, attitude
and practice triad
Diogo Thimoteo da Cunha a,1, Rose Magda Fiorotti b, 2, Juliana Garcia Baldasso c, 3,
Maricy de Sousa c, 3, Nathália Moretti Fontanezi c, 3, Simone Caivano c, 3, Elke Stedefeldt a,1,
Veridiana Vera de Rosso a,1, Maria Cristina Rubim Camargo c, *, 3
a
GeQual e Study Group of Food Quality, Federal University of São Paulo, Santos, Brazil
b
Prefeitura Municipal de São Caetano do Sul, São Caetano do Sul, Brazil
c
Instituto Nutra e Viva, Santana de Parnaíba city, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: The objective of the present study was to evaluate the development of food safety scores in school meal
Received 18 September 2012 services during the application of a systematic intervention based on the knowledge, attitude and
Received in revised form practice triad. A total of 68 public schools were included in the study. School meal services were assessed
27 May 2013
every three months with a checklist, which resulted in eight evaluations over two years. A program was
Accepted 4 June 2013
developed and implemented in all the schools during this period that was comprised of three steps: 1)
theoretical training, 2) implementation of action plans in situ and 3) weekly visits to motivate food
Keywords:
handlers and monitor good practices. These steps were designed to promote changes in the attitudes and
Training
Food safety
practices of food handlers. An ascending linear function was observed for the school meal services’
Food service general adequacy percentage over time. Positive developments were also observed regarding buildings
Food safety management and facilities, processes and procedures, distribution of meals, integrated pest management, water
Time series control, controls and records, health and safety of employees and equipment and utensils. Our results
School meals suggest that the proposed intervention strategy performs well in making school meal services conform
to good practices and that strategies in this context should be permanent and continuous.
Ó 2013 Elsevier Ltd. All rights reserved.

1. Introduction due to underreporting and the lack of full health monitoring sys-
tems, even in developed countries (Seaman & Eves, 2006).
Foodborne diseases are considered to be an emerging problem Several factors contribute to the incidence of foodborne disease,
and are currently a subject of major concern for the governments of including population growth, growth of highly vulnerable popu-
various countries throughout the world. Affecting both developed lation groups, lack of basic sanitation, increased food production
and developing countries, every individual in the world is at risk of and distribution and changes in consumer behavior toward a
foodborne disease (WHO, 2008). preference for high-risk foods (Motarjemi & Käferstein, 1999).
Food- and water-borne diseases contribute significantly to These factors are associated with human development and society
mortality due to diarrhea, responsible for 2.2 million deaths every rather than directly associated with food handlers.
year, mainly children in developing countries (WHO, 2008). How- Nonetheless, studies report that the inadequate handling of food
ever, the magnitude of the problem is believed to be even greater is considered the main causal mechanism of foodborne disease and
is directly related to several outbreak cases (Greig, Todd, Bartleson,
& Michaels, 2007; Howes, McEwan, Griffiths, & Harris, 1996). Out-
* Corresponding author. Tel.: þ55 11 3044 0693; fax: þ55 11 4192 2363. breaks usually involve cases of inadequate cooking temperatures
E-mail address: [email protected] (M.C.R. Camargo). and storage and cross-contamination between raw foods and
1
Address: Ana Costa avenue, 95, Vila Mathias, 11010-001, Santos city, SP, Brazil. ready-to-eat foods. In these cases, food handlers are estimated to be
2
Address: Fernando Simonsen avenue, 566, Bairro Cerâmica, 09540-230, São
Caetano do Sul city, SP, Brazil.
responsible for 97% of foodborne outbreaks (Egan et al., 2007).
3
Address: Alameda Brilhante, 673, Alphaville, 06540-115, Santana de Parnaíba Thus, strategies should be employed to ensure that food han-
city, SP, Brazil. dlers know good practices for food handling and that they use these

0956-7135/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.foodcont.2013.06.003
 D.T. da Cunha et al. / Food Control 34 (2013) 662e667 663

practices in their work environment. The most widely used strategy present in the Codex Alimentarius (2003). The checklist contained
is training, which is considered to be an important method to in- ninety-five items divided into eleven thematic areas: area one e
crease knowledge and skills (Medeiros, Cavalli, Salay, & Proenca, receipt, containing six questions; area two e storage, containing
2011). However, Ehiri, Morris, and McEwen (1994) reported that seventeen questions; area three e processes and procedures, con-
Good Hygiene Practice training, which involves only scientific taining twenty questions; area four e distribution of meals, con-
communication, is not an effective strategy for changing practices taining four questions; area five e pest control management,
in the workplace. Rennie (1994) stated that knowledge alone does containing two questions; area six e controls and records, containing
not result in changes in food hygiene practices. Failure to change four questions; area seven e waste management, containing six
behavior following training programs was also observed in other questions; area eight e health and safety of employees, containing
studies, which indicates that knowledge and practice are not al- three questions; area nine e water control, containing four ques-
ways associated (Cook & Casey, 1979; Park, Kwak, & Chang, 2010). tions; area ten e equipment and utensils, containing twelve ques-
This theory may be even more consistent than is observed in the tions and area eleven e structure and buildings, containing fourteen
literature, as scientific bias may cause articles that report negative questions. The checklist questions were given a score of one point for
results or intervention failures to remain unpublished (Dirnagl & compliant conditions and zero for non-compliant conditions.
Lauritzen, 2010; Schooler, 2011). Trained nutritionists applied the list to all schools participating
Therefore, new methods to promote good practices in food in the study, thereby providing a diagnosis of the sanitation and
service are needed to guarantee the quality of food provided. This hygiene conditions of the school meal services. This diagnosis stage
assumption becomes even more important in the context of was identified as time zero (t0) of the intervention.
school meal programs because these programs are meant to After applying the checklist, fitness scores were calculated for
provide food to children and young people to encourage their each thematic area. The scores were calculated as the number of
growth and biopsychosocial development (Oliveira, Brasil, & points achieved in the thematic area divided by the maximum
Taddei, 2008). number of points possible for that particular area and then con-
One of the most important public policies of the Brazilian fed- verted into a percentage. The same procedure was followed to
eral government to ensure the health of the population is the generate an overall adequacy score. This variable included all scores
provision of school meals, through the NSFP (National School obtained across the ninety-five items and corresponded to a mean
Feeding Program). The program began in 1955 and over the years adequacy for all thematic areas.
changes have occurred in its management until it was established, After discussing the strengths and weaknesses observed in each
in 1979, as the NSFP. Currently this program provides, through school meal service, an intervention program was proposed.
transfer of financial resources, the food supply for all students (from This intervention program was monitored by repeated applica-
day care centers, elementary schools, high schools and general tions of the same checklist used in the diagnostic stage. The
education for youth and adults) enrolled in public and philan- checklist was applied every three months, for a total of eight
thropic schools in Brazil. Approximately 45.6 million of school evaluations performed over a two-year period (t0, t1, t2, t3, t4, t5, t6
meals are served every day in Brazil (Peixinho, 2013). and t7). The purpose of this application was to monitor the
Brazil’s Good Manufacturing Practices (GMP) law does not behavior of the scores of each thematic area and the total scores
specifically address school kitchens, ruled by laws applied to of school meal services after the intervention program was
general food services. It must be considered that school kitchens implemented.
are, generally, adapted rooms or similar to home kitchens, resulting
in great difficulty in following GMP laws (Oliveira et al., 2008). 2.2. Intervention program
Thus, this program deserves special attention in relation to food
handling and the risks the ready-to-eat food can pose to students’ The proposed intervention program provides a new form of
health if food is mishandled. intervention to promote good practices in food service as it com-
The objective of the present study was to evaluate trends in bines strategies and concepts presented in other studies. The
sanitation and hygiene conditions within school meal services knowledge, attitude and practice triad serves as the central axis of
during the application of a systematic intervention program based the intervention program (Bas, Ersun, & Kivanc, 2006; Sharif & Al-
on the knowledge, attitude and practice triad. Malki, 2010) and the program evaluation uses hybrid models
(combination of internal and external evaluation) (Bourgeois, Hart,
2. Methods Townsend, & Gagné, 2011); the program also includes scheduled
monitoring of good practices (Bader, Blonder, Henriksen, & Strong,
The present study included all public schools (n ¼ 68) of a highly 1978) and motivation of food handlers (Seaman, 2010).
developed municipality of São Paulo (Brazil) with a 0.8340 Human Systematization of the intervention model was adapted from
Development Index (UNDP, 2000). Schools participating in the Seaman (2010) (Fig. 1).
study covered all age groups involved in basic education, including The intervention consisted of three stages: 1) theoretical
kindergarten, preschool, elementary, middle and high schools for training focused on improving knowledge, which was held every
young people and adults. A total of 365 food handlers participated six months; 2) good practices evaluation and implementation of
in the intervention and were distributed among the school meal in situ action plans to correct nonconformities and to align
services being evaluated. practices, every three months and 3) weekly visits to all school
None of the school meal services had implemented the Hazard kitchens to monitor action plans and motivate food handlers.
Analysis and Critical Control Points (HACCP) program before the The first and second stages were conducted by nutritionists
intervention. outside of the school meal services (external assessment and
intervention) and the third stage was conducted by trained tutors
2.1. Checklist and application and staff from the municipality (internal assessment and
intervention).
A good practice checklist was developed based on current legis- A total of five 12-h theoretical trainings were performed. Each
lation in Brazil, including CVS-18 (São Paulo, 2008), RDC 216 (Brazil, training included three breaks for meals. These trainings were
2004) and CVS-6 (São Paulo, 1999), and on the food standards conducted in classrooms with a maximum of thirty food handlers
664 D.T. da Cunha et al. / Food Control 34 (2013) 662e667

Overall performance of school meal service and individual performance of food handlers

Adequate food
handling Effect of social Inadequate food
Structural practices habits, routines handling practices
adjustment and and components
purchase of
materials and
equipment Food handlers’ intentions to change attitudes

Requesting 1) Training 2) In situ 3) Monitoring

structural focused on implementation of (internal
reforms and improving action plans assessment)
purchases of knowledge focused on focused on
materials and (every 6 months) changes in motivation and
equipment practice maintaining changes
(Every 3 months) in practice

Proposal for intervention

Document with positive and negative aspects of the school meal services

Application of checklist (external evaluation)

Fig. 1. Flow of systematic intervention program based on the knowledge, attitude and practice triad applied to school meal services.

in each group. They included dialogical lectures and projected handlers who had been trained to develop monitoring for school
presentations on the following issues: food contamination, meal services and were therefore considered internal evaluators.
receiving, storage, processes and production, distribution, pest During this stage, food handlers were invited by the tutors to report
control, waste management, food handlers’ health and safety, any difficulties in the workplace and to make suggestions for
environmental hygiene, equipment and utensils, visitor pro- improvement of the sanitation practices. This stage was also
cedures, operation of the milk dispensary, records and controls, designed to monitor the progress of action plans by evaluating the
quality assurance, procedures for freezing goods, sampling and adequacy of the procedures performed.
interpersonal relationships. All training topics were selected based At the end of each quarterly assessment, a report was issued and
on the results obtained from the assessments carried out with the copies were sent to the municipality’s school food sector for re-
school meal services. Food handlers were given handouts and ferrals relating to management, procurement and reforms.
materials on the topics covered in training. External evaluating
nutritionists provided the instruction at this stage. At the end of the 2.3. Data analysis
training, all food handlers were given an assessment with questions
about the topics covered. Trend analysis using regression models was chosen for the data
The second stage of the intervention, which corresponds to the analysis. This analysis facilitated evaluation of the behavior of the
action plan, was planned and performed individually and in situ dependent variable (Y), the good practices adequacy percentage, in
within the school meal services by a team from outside the mu- relation to the evaluation periods (X). A total of eight evaluations
nicipality, during the same week in which the quarterly evaluation occurred every three months.
was held. The aim of this stage was to correct specific inadequacies First, scatter diagrams were made showing the relationship
observed in each school kitchen. During this stage, inadequacies between the adequacy percentages and the time variables to verify
regarding good practices were noted for all food handlers and the type of relationship between these variables.
targets were drawn up for the next evaluation to be implemented The time variable (X) was centralized, therefore “X-11.5” was
in three months. used, where 11.5 is the mean time in months of the study period.
The action plan consisted of the following items: identification This procedure prevents collinearity between terms of the regres-
of inadequacies, determination of corrective actions, individual sion equation.
orientation of the food handlers with the demonstration of correct First, the simplest linear regression model was tested
procedures, observation of the handlers’ practices and goals for the (Y ¼ b0 þ b1X). Based on the function identified in the scatter dia-
next quarterly review. Order requests were submitted to the school gram, models of higher orders were also tested, including
board and the school meal services coordinator when structural second degree (Y ¼ b0 þ b1X þ b2X2), third degree
problems were noted, equipment and utensils were needed or any (Y ¼ b0 þ b1X þ b2X2 þ b3X3) and exponential (ln (Y) ¼ ln
other factor regarding management and/or use of resources was (b0) þ (b1X)) models.
identified. The model that showed greater statistical significance and
The third stage included an individualized weekly visit to each normal residuals was considered the best-fit. Models with p < 0.05
school meal service performed by tutors. These tutors were food were considered significant.
 D.T. da Cunha et al. / Food Control 34 (2013) 662e667 665

3. Results and discussion effect was demonstrated with linear and coefficient of determina-
tion models above 0.50 for all tests. This indicates that up to 50% of
A total of 512 evaluations were performed, corresponding to the variation between evaluations can be explained as a function of
eight assessment points for each of the sixty-eight school meal time, and therefore, of the intervention.
service research participants. Using a quadratic model, favorable development was observed
in the controls and records thematic area (Fig. 2B). This model in-
3.1. Evaluation of the intervention program dicates that despite positive development, in the period between
the second and fourth assessment, there was a reduction in correct
Table 1 shows the regression models for each thematic area practices in relation to the completion of temperature control
evaluated. The first value of the equation is the mean adequacy sheets and labels with usage information and food validity. Lockis,
percentage followed by its increment (positive or negative) after Cruz, Walter Faria, Granato, & Sant’Ana (2011), in a cross-sectional
each intervention; the explanatory power (r2) and significance (p) study of school meal services, observed that the filing of records
of each model are also listed. and controls was the third largest inadequacy observed with
An ascending linear function was identified for the overall ad- respect to good practices. These results show that food handlers
equacy percentage, showing that the intervention strategy used may exhibit resistance to the completion of records and controls,
explains 87% of the improvement in good practice scores over the but the intervention proposed here improved adequacy in this area
observation period (p < 0.01). Therefore, the intervention strategy by 33.4% over two years.
tends to bring food services into line with health legislation. Bader Positive effects of food safety-related interventions in terms of
et al. (1978) evaluated food service establishments and showed that changing practices have been observed in different contexts, such
sites that received four health inspections per year obtained final as hospitals (El Derea, Salem, Fawzi, & Abdel Azeem, 2008), street
good practice scores 47% higher than sites that only had one in- food vending (Choudhury, Mahanta, Goswami, & Mazumder, 2011),
spection performed. This result shows that systematic and frequent small businesses (Bush et al., 2009) and with those responsible for
visits help in the motivation and monitoring of food services; food services (Kassa, Silverman, & Baroudi, 2010). However, no
therefore, they improve good hygiene practices. Has been recently studies have been conducted using strategies with school meal
published a specific good practice checklist for Brazilian school services that demonstrate a positive effect on practices.
meal services. This tool can be an option to assess and monitor the The thematic areas of integrated pest management (Fig. 2B) and
food safety on this environment (Stedefeldt, Cunha, Silva Junior, health and safety of employees (Fig. 2D) reached nearly 100% ad-
Oliveira, & Silva, 2013). equacy, with 98.6% and 95.3% adequacy, respectively. For integrated
Fig. 2 shows the regression models of the thematic area vari- pest management, the most influential positive factor was adjust-
ables over the eight ratings. Reduction in the overall adequacy ment in the frequency of chemical control use and the archiving of
percentage in month ten (fourth assessment) was observed probative documents. About the thematic area of health and safety
(Fig. 2A). In addition to the overall percentage, small reductions of employees, the training adequacy, purchasing of utensils and
occurred in the following thematic areas: equipment and utensils, frequency of medical exams contributed to the achieved adequacy.
buildings and facilities (Fig. 2A), processes and procedures, controls The waste management thematic area showed a negative
and records (Fig. 2B) and storage (Fig. 2C). These adequacy per- increment (p < 0.01), and the receiving and storing blocks did not
centage reductions coincided with holiday periods for the food change significantly between assessments. Handlers most likely
handlers. Absence from the workplace most likely led handlers to failed to prioritize these activities in relation to others because they
resume incorrect practices that had previously been corrected. were identified as low risk for foodborne disease. Internal evalua-
Therefore, interventions should be continued and strengthened tors may also not have prioritized these steps, failing to monitor
especially after holiday periods to avoid inadequacies. Furnari et al. them and propose corrections.
(2002) observed that ongoing training reduced the resistance of Such factors depend on the perception of risk involved. Food
food handlers to using food handling knowledge in their practice. handlers were shown to have reasonable perception of foodborne
When the thematic areas were analyzed separately, positive illness risks in a study performed with school meal services (Da
increments were observed in the following areas: buildings and Cunha, Stedefeldt, & De Rosso, 2012). This perception increased
facilities (p ¼ 0.01), processes and procedures (p < 0.01), meal with participation in mandatory training. Lower adequacy per-
distribution (p < 0.01), integrated pest management (p < 0.01), centages for waste management have also been reported (Cardoso
health and safety of employees (p < 0.01), water control (p < 0.01) et al., 2011; Lockis et al., 2011) and may be a reflection of the low
and equipment and utensils (p < 0.05). In this case, the positive perception of risk for this activity by food handlers in these
locations.
Table 1
Regression equations, explanatory power and significance of the development of the 3.2. Practical implications
overall good practices adequacy percentage and adequacy percentage of the the-
matic areas evaluated. The intervention strategy used combined internal and external
Thematic areas Model r2 p evaluation. This combination provides results closer to reality and
facilitates the planning of interventions. Internal assessment pro-
Buildings and facilities y ¼ 50.83 þ 0.903x 0.79 <0.01
Receipt y ¼ 63.11 þ 0.140x 0.007 0.842
vides deep insight into the organization and work, facilitating
Storage y ¼ 78.36 þ 0.045x 0.04 0.618 decision-making (Bourgeois et al. 2011). The internal evaluator
Processes and procedures y ¼ 66.82 þ 0.328x 0.83 < 0.001 tends to understand cultural and political motivations behind
Distribution of meals y ¼ 45.04 þ 1.955x 0.88 <0.001 behavior in the service (Conley-Tyler, 2005). Moreover, the evalu-
Integrated pest management y ¼ 83.79 þ 1.845x 0.76 <0.01
ator understands well the nature of the results, and thus the results
Controls and Records y ¼ 20.75 þ 1.610x þ 0.122x2 0.91 <0.01
Waste Management y ¼ 47.55  0.816x 0.88 <0.001 can be used more effectively (Minnett, 1999). The external evalu-
Health and safety of employees y ¼ 88.18 þ 1.264x 0.68 <0.01 ator has greater access to information because people tend to be
Water control y ¼ 40.68 þ 2.202x 0.97 <0.001 more sincere about their problems with people who are not
Equipment and utensils y ¼ 77.78 þ 0.599x 0.50 <0.05 involved in their daily routine (Conley-Tyler, 2005). Additionally,
Overall adequacy percentage y ¼ 64.77 þ 0.572x 0.87 <0.001
the external evaluator more easily identifies errors inserted into
666 D.T. da Cunha et al. / Food Control 34 (2013) 662e667

Fig. 2. Regression models for the overall good practices score and thematic areas monitored during application of the intervention model for school meal services.

work routines, evaluating the service with greater objectivity and actions as low risk for food contamination. However, this hypoth-
reduced bias, which is fundamental, especially with regards to esis needs to be tested.
summative assessments (Bourgeois et al., 2011; Conley-Tyler, Another important finding observed in this study was the
2005). reduction in the overall adequacy percentage after food handlers’
Another important practical implication is that in 2007 Brazil holiday periods. Permanent intervention strategies should be
began to work together with the World Food Programme (WFP) of prioritized with emphasis on the period after vacation periods and
the Food and Agriculture Organization of the United Nations (FAO) sick leave.
in the structuring of school feeding programs in several countries in Importantly, intervention strategies for food handlers’ practices,
Latin America, the Caribbean and Africa (Organization of American even successful ones, should not be observed as a panacea for
States, 2008). The development and improvement of materials to problems involving foodborne diseases. Several aspects influence
ensure food security cannot only benefit the Brazilian school sanitation and hygiene practices in food service units, and those
feeding program, but also help other countries that cooperate with responsible must carry out constant monitoring, food handler
Brazil. motivation, structural reforms and quality assurance of food and
raw materials, among other actions.
4. Conclusion The performance of this strategy may be observed in other food
service areas, such as restaurants, hospitals and even the street
The systematic intervention strategy proposed by the present food.
study was effective in improving school meal services’ adequacy in
terms of food service hygiene laws.
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