Hospital food safety presents considerable challenges, particularly for patients who are more susceptible to microbiological and nutritional hazards compared to healthy individuals. With the onset of COVID-19, food safety regulations have gained increased significance.
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Abstract
Hospital food safety presents considerable challenges, particularly for patients who are more susceptible to microbiological and nutritional hazards compared to healthy individuals. With the onset of COVID-19, food safety regulations have gained increased significance. The objective of this study was to design and validate a questionnaire for assessing food safety knowledge, perceptions, and practices (KPPs) among hospitals food service staff (FSS) in the context of the COVID-19 pandemic.
Methods
A literature review and focus group discussions were employed to develop questions essential for evaluating KPPs related to food safety among Jeddah city hospitals FSS. The study was carried out from Jan to Apr 2022. The focus groups consisted of 10 hospital FSS employees, 10 general population representatives, and eight food service experts who refined the questions. A 127-item questionnaire was devised, followed by a pilot study involving 40 FSS. A cross sectional study using a questionnaire was adopted. Subsequently, the questionnaire was revised and translated into Arabic, yielding a final version with 115 KPP items.
Results
The ultimate output was a 115-item questionnaire in English, with a content validity ratio (CVR) of 0.96. Statistically significant correlations were observed for scaled items (p < 0.01). All items related to perceptions and practices yielded a Cronbach’s Alpha of 0.914, indicating strong internal consistency.
Conclusions
The constructed questionnaire demonstrates validity and reliability in evaluating KPPs among FSS within the COVID-19 context. This instrument can be applied across diverse hospital environments to gauge KPPs and staff readiness for food safety, thereby mitigating the risk of foodborne illnesses.
Keywords: COVID-19 pandemic, Healthcare facilities, SARS-CoV-2, Foodborne diseases, Food handlers, Food safety, Food services
Introduction
Food safety is crucial for maintaining good health. Recent research has revealed that foodborne diseases (FBDs) outbreaks in hospitals may be caused by an inability to store food at correct temperatures, cross-contamination of food due to unhygienic handling practices, poor personal hygiene, purchasing food from untrustworthy sources, and/or lack of food safety awareness . A lack of a culture of food safety can lead to several food hygiene violations, and can easily result in serious illnesses for patients or in outbreaks of FBDs in healthcare facilities. Thus, hospital food services play an essential role in patient care .
Food services facilities in hospitals prepare and serve food in high-risk environments to patients who have low or compromised immunity; therefore, FBDs can be spread easily. Since, the COVID-19 outbreak, food safety rules have become even more essential, given that poor food safety KPPs among FHs may play a major risk in spreading FBDs in healthcare facilities. Therefore, hospital FHs must have adequate knowledge of food safety, from procurement to serving, in order to ensure that the food is safe when it reaches patients .
SARS-CoV-2, the virus that causes COVID-19 infection, can remain viable for up to 72 hours on inanimate objects after completing its lifecycle in the body of an infected person . Therefore, if the respiratory discharges of a person infected with SARS-CoV-2 come in contact with food, the contaminated food items can theoretically become a temporary carrier if touched by another person that later touches his/her nose, eyes, or mouth without first washing or sanitizing hands .
Food handler (FHs) play an essential role in food safety and in the spread of FBDs because they can introduce pathogens into food served to the patients in the production, processing, distribution, and/or preparation stage. Therefore, well-developed, and validated instruments are needed for assessing the food safety practices adopted by the FHs in healthcare facilities . If a questionnaire of an unknown validity or reliability was used, it would be hard to determine whether the findings were accurate .
Nevertheless, accumulated knowledge about the evaluation of food safety awareness of the food service staffs in hospitals in the COVID-19 pandemic is quite limited so far, and to our knowledge, there is paucity of validated survey instruments that can be adopted for this purpose. Hence, the study was focused to develop and validate an easy to administer and concise tool that will help stakeholders and researchers to assess, measure, and understand key areas within food safety, which is especially important in the COVID-19 era, as well as to increase awareness that will help hospitals by providing the highest possible quality of food service while reducing the risk of patients contracting FBDs.
Materials and Methods
This study was conducted across three sequential phases, comprising instrument development, validation, and translation, as shown in Figure 1. The study was approved by the Research Ethics Committee of the King Abdulaziz University, Saudi Arabia (approval No. HA-02-J-008). The study adopted a structured, self-administered questionnaire to get data from the participants and informed consent was obtained from all participants. The study was carried out from Jan to Apr 2022 in hospitals Jeddah, Saudi Arabia. A cross sectional study using a questionnaire was adopted. All methods were performed in accordance with the relevant guidelines and regulations. Several approaches were adopted when developing a comprehensive instrument, including a review of current regulations and relevant literature, and conducting focus groups and expert interviews. In this study, instrument development was conducted across three stages, as explained below. The factors considered for this instrument were based on the food safety regulations during the COVID-19 pandemic, focusing on the four most significant factors to be controlled to prevent foodborne diseases (clean, separate, cook, chill). For this purpose, Food and Drug Administration (FDA), United States Department of Agriculture (USDA), and Centers for Disease Control and Prevention (CDC) guidelines, as well as the Saudi Arabia Ministry of Health (MOH) guidelines were examined . In addition, pertinent items from other published studies were incorporated into the preliminary questionnaire .
The first draft of the questionnaire was prepared in English including 127 items under four sections: demographic information, and KPPs related to personal hygiene, food poisoning, cross-contamination, preparation, storage, and cooking in healthcare facilities. Section one (demographic) included seven demographic items (gender, age, education level, working experience, and food safety training courses, types of training courses, and position). Section two (knowledge) included 52 multiple-choice items (42 related to general food safety knowledge and 10 pertaining to food safety knowledge during the COVID-19 pandemic). These items focused on cross-contamination, diseases that require restriction or exclusion from working in or around food preparation area, personal hygiene, temperature control, general food safety rules, and other food safety rules in place during the COVID-19 pandemic. Section three (perceptions) included 29 statements (19 to assesses general food safety perceptions and 10 to assess food safety perceptions during the COVID-19 pandemic) rated on a 5-point Likert scale (Strongly disagree = 1, Disagree = 2, Neither agree nor disagree =3, Agree = 4, and strongly agree =5). Section four (practices) comprised of 39 questions (20 to assesses general food safety practices and 19 to assess food safety practices during the COVID-19 pandemic) rated on a 5-point Likert scale (Never = 1, Rarely = 2, Sometimes = 3, Often = 4, and always = 5). This section included questions pertaining to personal hygiene, temperature control, cross-contamination prevention, cleaning, storage, and right steps to store and display foods.
Three small focus group discussions were conducted. The first one included 10 adult members of general public of diverse educational levels, as described by Chopra et al. . The second FGD was held with 10 FSS at different training levels, all of whom were responsible for food handling in healthcare facilities. Both FGDs were guided by a facilitator. As described by Chopra et al. the third FGD involved eight experts recruited from the food and nutrition departments of different universities. Based on their extensive expertise in the field, they were invited to review the overall instrument, as well as suggest addition, removal or rewording of certain items.
Face validity refers to the extent of which a test appears to measure what it is intended to measure , while the term “content validity” refers to the extent of which the items in a questionnaire are representative of the entire theoretical construct the questionnaire is designed to assess . In this study, content and face validity assessments were performed on the English version of the questionnaire. Twenty experts in the field were recruited from hospitals’ Food Service Departments in Jeddah and the Department of Food and Nutrition Science at King Abdulaziz University, and Tabuk University for this purpose. All experts had more than five years of work experience, were well versed in English, and were provided with detailed information regarding the research process and their role. Ten experts were responsible for assessing the face validity as well as language appropriateness, format, reasonableness, readability, consistency, and logical sequence of items.
Content validity was evaluated by the remaining 10n experts by comparing the content of each question and carefully considering question type and construction. In this process, the experts were asked to rate the necessity of each question using the 3-point Likert rating scale proposed by 1 = not necessary; 2 = useful but not necessary; and 3 = essential. The content validity ratio was computed for each questionnaire item based on the following formula developed by :
Where:
ne = number of experts indicating that a measurement item is essential, and
N = total number of experts that rated the item.
In Preliminary pilot testing phase, quantitative methods were utilized for establishing the construct validity and reliability of the questionnaire. The preliminary version of the questionnaire was pilot tested by administering it to 40 randomly selected hospital staff members responsible for food handling. All participants were briefed about the purpose of the study and instructed to respond based on their work practices in food service facilities. Those who agreed to participate provided their written informed consent prior to completing the questionnaire. No monetary compensation was given for participation.
As the 62 knowledge questions were in multiple choice format, descriptive statistics such as frequencies and percentages were used to evaluate the knowledge of food safety among FSS.
The internal consistency of the scale questions (24 items for perceptions, and 25 items for practices) was assessed by using Pearson’s correlation. The internal consistency is the extent to which the items from a measure represent the variable they are intended to measure. Correlation coefficients used to evaluate the internal consistency between the survey items and the factors to which they belong to (perceptions and practices regarding food safety among food service staff in general and during COVID-19), which is the correlation between each statement and the total of the factors where it belongs to .
The reliability of the scale questions (24 items for perceptions, and 25 items for practices) was assessed by using Cronbach’s alpha, as it is the most common measure of the reliability of scales involving Likert-type questions that have latent variables (hidden or unobservable variables). Cronbach’s alpha is a measure used to assess the reliability of a set of test items to determine how closely related this set of test items are as a group .
In Translation of tools/instruments phase, the final version of the English version of the questionnaire was translated by two translation teams. The translation teams were formed to ensure that the documents translated from the source language (English) into the target language (Arabic) are equivalent in terms of semantics, concepts, and norms, as well as being trustworthy, comprehensive, accurate, and culturally appropriate. According to the Census Bureau’s Guideline for the Translation of Data Collection Instruments and Supporting Materials, the translation process followed five steps, denoted as preparation, translation, pretesting, revising, and documentation .
Each of the two translation teams consisted of a bilingual subject matter expert researcher, and translators who have the necessary skills, knowledge, and professional experience in questionnaire translation. These teams worked separately before comparing their work to identify any ambiguities and discrepancies in words, sentences, and meanings, and settle on a single version that incorporates the best aspects of the independent translations .
In preparation for translation step, each translation team was provided with a statement of work that details the objective of the translation, the intended audience, the mode in which the instrument will be administered (self-administered or interviewer-administered data collection), the target language, and the level of formality. In addition to the text designated for translation, the translation teams received all documentation that would be useful in performing the translation, such as the definitions of terms or concepts used in the wording of the questions . Two forms-“criteria for achieving a good translation (Appendix A)” and “translation validation form (Appendix B)”-were adopted from the Census Bureau’s “Translation of data collection instruments and supporting materials” for this study .
The translation step consisted of a direct translation from the source language (English) to the target language (Arabic). Two separate translator teams performed the translation, as described above. According to the criteria recommended by the Census Bureau’s ‘Guideline for the translation of data collection instruments and supporting materials; to achieve the goals of a good translation, both teams were familiar with the concepts in the questionnaire, such as: Who is the target population, including their level of education? Why is the document needed? In what social setting will the document be used? What is the mode of data collection? What is the manner of delivery (formal, informal)? All comments and perspectives concerning the questionnaire were recorded on a form prepared for this purpose (Appendix C), and then the researchers and translation teams discussed and revised the final translated version based on their findings
In Pretesting of the translated questionnaire, accordance with the protocol outlined by , a qualitative concurrent cognitive interview technique was used to pretest the translated version of the questionnaire in this study. The cognitive interview protocol was designed to evaluate the fluency and appropriateness of the translated materials. The probes examined the comprehension of key terms in the questions as well as the overall comprehension of the items (Appendix D). This technique consists of verbal probes that enable researchers to analyze in depth how survey respondents understand the questions (e.g., “Can you explain in your own words what this question means to you?”). This allows participants to rephrase the questions in their own words immediately after answering them, allowing researchers to determine whether participants fully comprehend the questions .
After completing the translation process as described previously, the researchers asked ten randomly selected target participants to verbally explain the meaning of each item and its corresponding response. All discrepancies between the original and translated meanings were recorded by the researchers and discussed with the translation teams so that the final version could be revised. This procedure was repeated multiple times to finalize the translated questionnaire and to ensure that the translated items convey the same meaning as their original equivalents and that the translated questionnaire does not lead to misinterpretation .
Revision is a necessary and integral part of the translation process that continues until the translation is finalized. As described by , in this study, the first revision was performed following the review of the initial translated document and was conducted again after the pretest. The translation team reviewed and revised the questionnaire based on the pretest results and by comparing source-language and target-language definitions and concepts. Adjudication of disagreement between translators was achieved by critical review of the comments provided by participants via cognitive interview/debriefing (Appendix D) before finalizing the translated documents .
For the preparation documentation step, translator teams received a written specification containing all relevant documentation for performing the translation, as outlined earlier . For the translation step, a numbering system for tracking different versions was developed. All comments, perspectives, revisions, and decisions were recorded and documented on the translation teams’ comments and perspectives form (Appendix C), and then the preliminary translation version was revised.
The cognitive interview protocol was designed for the pretesting step to evaluate the fluency and appropriateness of the translated materials (Appendix D). The probes examined the comprehension of key terms in the questions as well as the overall comprehension of the items. Before finalizing the translation, all verbal responses were recorded and discussed with the translation teams in order to be modified.
During the revision process, source-language and target-language definitions and concepts were compared to ensure that the translated version has the same meaning as the SLQ. The word definition list was utilized by translation teams and interviewers when conducting interviews with the selected respondents (Appendix F and G).
Figure 1. Flow chart of the process adopted when developing the survey instrument.
The statistical package for social sciences (SPSS version 25) was used for data analysis. Cronbach’s alpha was calculated to assess the reliability of the questionnaire, while internal consistency was assessed via Pearson’s correlation. Frequencies, percentages, and mean scores were also calculated for descriptive results.
Data availability: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Results
During the first FGD conducted with 10 members of the general public, questionnaire items were discussed to assess their understanding of the topics, and to obtain their feedback regarding the clarity of the questions.
The second FGD was held with 10 FSS at different training levels who were responsible for food handling in healthcare facilities. The purpose of this meeting was to determine the clarity of the questionnaire items and their relevance with respect to the food safety rules that should be followed in healthcare facilities. Based on these discussions, it became evident that some words and phrases such as “cross-contamination,” “temperature abuse,” and “temperature danger zone” needed to be explained in the questionnaire. In addition, the question “At what temperature do pathogens best grow?” was replaced by “Which of the following is considered the ‘temperature danger zone’?”
The third FGD was held with eight experts in the field, who suggested modifying 11 items by stating the type of potential hazard (biological, chemical, or physical) that might be associated with specific questionnaire items. In addition, items 47-55 pertaining to diseases (which require restriction or exclusion from working with food or around food preparation area) were modified to add a list of different diseases, requiring that the respondents indicate those that require reporting to the responsible supervisor. Moreover, 20 duplicate or impertinent items were eliminated (10 from knowledge, three from perceptions, and four from practices section). Thus, the second draft of the questionnaire, comprising of 118 items, some of which were modified, was subjected to face and content validity assessments, as outlined below.
Face validity: For face validity, expert feedback was taken into consideration and some words were rephrased into lay terms or explained (e.g., “food handlers” was changed to “food handlers such as chefs and food preparation area workers”), and “I don’t know” option was added to the multiple-choice constructs.
Three further items were revised or rephrased because they were considered insufficiently understandable by the experts. Thus, Item 81 “Color coding in cutting boards equipment, and utensils, such as knives, will reduce cross-contamination” was replaced with “Encoding the colors of cutting boards, equipment and utensils such as red color use for red meat and green color for vegetables, reduces cross-contamination.” In addition, Item 25 “Cooking food to less than 74 °C for 15 seconds” was replaced by “The internal temperature when cooking does not reach 74 °C (for at least 15 seconds)” and Item 85 “Food handlers can be a source of foodborne diseases” was replaced by “Food handlers such as chefs and food preparation area workers generally can be a source of foodborne diseases.”
As the evaluation of the face value of the questionnaire confirmed that no items needed to be deleted, all 118 items remained.
Content validity: Content validity was expressed as the Content Validity Ratio (CVR), whereby CVRs were calculated for all questionnaire items, and the average CVR score for all items was calculated to determine the total CVR score for the instrument. The minimum CVR needed to retain the item in the questionnaire was determined using the Lawshe table
After Calculation of CVR, 117 of the 118 items received CVR scores greater than 0.62 (the minimum value required for good content validity by the experts). The remaining item (which received CVR = 0.4) was revised by replacing “Leaving food inside the temperature danger zone (between 5 °C and 60 °C) for more than 2 hours is unsafe” with “It is unsafe to leave food inside the temperature danger zone (between 5 °C and 60 °C) for more than 2 hours.” Following this revision, a total CVR of 0.96 was obtained for the instrument, indicating good overall CVR.
The second draft of the questionnaire was pilot tested on 40 respondents to assess the construct validity and thus ensure internal consistency. In addition, descriptive statistics were calculated for all non-scaled items.
Only scaled statements were included in validity testing, which involved calculation of Pearson’s correlation coefficients, and the results are reported in Table 1. As the correlation coefficients for all items (except one) were statistically significant (p < 0.01), the problematic item was excluded.
The correlation is significant at the 0.05 level.
**Correlation is significant at the 0.01 level
Only scaled items were subjected to reliability testing, and the obtained Cronbach’s alpha values are reported in Table 2, whereby 0.7 or higher values were considered to indicate good reliability . As can be seen from the results, the scales evaluating the food safety perceptions and practices among food service staff are reliable, as the corresponding Cronbach’s alpha was 0.875 and 0.830, respectively. On the other hand, Cronbach’s alpha for the food safety perceptions (0.712) and practices (0.727) among food service staff during COVID-19 were somewhat lower, but the scales were still acceptable. The overall Cronbach’s alpha (0.914) indicated that the reliability of the entire instrument was excellent.
Discussions
Hospital food services are crucial to patient care . Since the COVID-19 outbreak, food safety rules have become even more essential, as food handlers can spread the virus by coughing, speaking, breathing, sneezing, or even singing. All these activities can create infectious aerosols that may contain pathogens that then transfer to the surrounding air and objects, thereby impacting patients, customers, and staff . The questionnaire developed in this study was based on significant aspects of food safety in healthcare facilities. A unique feature of the developed questionnaire is that it evaluates food safety knowledge, perceptions, and practices among food service staff in hospitals during the COVID-19 pandemic.
To facilitate questionnaire development, pertinent literature was consulted , along with the food safety regulations during COVID-19 released by the USDA, MOH, CDC, and FDA, focusing on the significant factors (clean, separate, cook, chill) to be controlled to prevent foodborne diseases.
The methodology used in this study when developing, translating, and validating the food safety survey instrument was based on the guidance provided by , as these authors developed similar instruments to assess hospital food service staff knowledge, perceptions, and practices during the COVID-19 pandemic.
According to , a focus group discussion is a way to bring together people that have certain traits in common to talk about a particular subject of interest. These group discussions allow researchers to clarify, elaborate, and better understand the ideas and viewpoints of their target group. As they can also reveal potential issues with questionnaire design and stimulate new ideas and concepts , they are used in different disciplines . In this study, three FGDs were conducted, allowing researchers to assess the instrument’s clarity and relevance from the perspective of the general public, food service staff, and experts. Their views were considered when revising the questionnaire. Its content validity was also assessed using the Lawshe method and the CVR of 0.96 indicated good content validity.
The first draft of the questionnaire was pilot tested by administering it to randomly selected 40 hospital food service staff. As explained by , the main objective of the pilot test is to evaluate the research tools, verify the degree of ease in its application, and the adequacy of the terms, as well as to facilitate comprehension by the evaluator on the items and sub-items After the pilot study, the revised questionnaire had 115 items.
This version was subjected to descriptive analysis, which confirmed that the majority of respondents were well-versed in all subjects addressed in the survey. Similar findings were established by among 163 food service staff from 10 hospitals in Al Madinah, Saudi Arabia. The results also concurred with those reported by based on a survey of 120 food handlers working in companies that provide food to hospitals in Beirut, Lebanon.
It is worth noting that found that most of the food handlers did not know the minimum internal cooking temperature for different types of foods, indicating that the instrument developed as a part of this study would be a useful tool for assessing their general food safety knowledge. Similarly, noted that 76.2% and 70.6% of 235 food handlers surveyed in 29 institutions in Ghana were not aware that salmonella and Hepatitis A are foodborne pathogens, respectively. As who surveyed 532 food service staff in 37 hospitals in Jordan (public, private, and university hospitals) also found that a significant percentage of their respondents lacked adequate knowledge of foodborne pathogens and related symptoms and illnesses, the section in our instrument related to these topics was highly relevant. We also addressed knowledge of cross-contamination, which was found inadequate in previous studies .
Our instrument was assessed for internal consistency, and the findings confirmed that it has been achieved, as the overall Cronbach’s alpha reliability of all instrument scales (0.914) exceeds the 0.7 threshold
Finally, as the instrument was initially developed in English, the translation to Arabic was performed by experts to ensure that the Arabic translations retained the original meaning. However, on the advice of the Census Bureau expert panel, backward translation was not performed, as it frequently does not result in instruments of acceptable quality for data collection .
Conclusion
The paucity of validated survey instruments that can be adopted by healthcare facilities to evaluate food safety status among FSS who provide food to vulnerable hospitals patients emphasized the need of developing and validating an instrument for this purpose. In this study, a survey developed, tested, and validated to cover all the important aspects for assessing KPP of food safety among FSS. The developed instrument is reliable, valid, concise, and easy to administer tool that will help stakeholders and researchers to assess, measure, and understand key areas within food safety in healthcare facilities, which is especially important in the COVID-19 era. Such instruments will increase awareness and help hospitals provide the highest possible quality of food service, while reducing the risk of patients contracting FBDs. This instrument is recommended to be used in healthcare facilities in normal cases or during FBDs outbreak or health crises such as COVID-19 pandemic, as it covers important aspects to be evaluated and emphasized during food production in healthcare facilities.
6. Reference
Abstract
Hospital food safety presents considerable challenges, particularly for patients who are more susceptible to microbiological and nutritional hazards compared to healthy individuals. With the onset of COVID-19, food safety regulations have gained increased significance. The objective of this study was to design and validate a questionnaire for assessing food safety knowledge, perceptions, and practices (KPPs) among hospitals food service staff (FSS) in the context of the COVID-19 pandemic.
Methods
A literature review and focus group discussions were employed to develop questions essential for evaluating KPPs related to food safety among Jeddah city hospitals FSS. The study was carried out from Jan to Apr 2022. The focus groups consisted of 10 hospital FSS employees, 10 general population representatives, and eight food service experts who refined the questions. A 127-item questionnaire was devised, followed by a pilot study involving 40 FSS. A cross sectional study using a questionnaire was adopted. Subsequently, the questionnaire was revised and translated into Arabic, yielding a final version with 115 KPP items.
Results
The ultimate output was a 115-item questionnaire in English, with a content validity ratio (CVR) of 0.96. Statistically significant correlations were observed for scaled items (p < 0.01). All items related to perceptions and practices yielded a Cronbach’s Alpha of 0.914, indicating strong internal consistency.
Conclusions
The constructed questionnaire demonstrates validity and reliability in evaluating KPPs among FSS within the COVID-19 context. This instrument can be applied across diverse hospital environments to gauge KPPs and staff readiness for food safety, thereby mitigating the risk of foodborne illnesses.
Keywords: COVID-19 pandemic, Healthcare facilities, SARS-CoV-2, Foodborne diseases, Food handlers, Food safety, Food services
Introduction
Food safety is crucial for maintaining good health. Recent research has revealed that foodborne diseases (FBDs) outbreaks in hospitals may be caused by an inability to store food at correct temperatures, cross-contamination of food due to unhygienic handling practices, poor personal hygiene, purchasing food from untrustworthy sources, and/or lack of food safety awareness . A lack of a culture of food safety can lead to several food hygiene violations, and can easily result in serious illnesses for patients or in outbreaks of FBDs in healthcare facilities. Thus, hospital food services play an essential role in patient care .
Food services facilities in hospitals prepare and serve food in high-risk environments to patients who have low or compromised immunity; therefore, FBDs can be spread easily. Since, the COVID-19 outbreak, food safety rules have become even more essential, given that poor food safety KPPs among FHs may play a major risk in spreading FBDs in healthcare facilities. Therefore, hospital FHs must have adequate knowledge of food safety, from procurement to serving, in order to ensure that the food is safe when it reaches patients .
SARS-CoV-2, the virus that causes COVID-19 infection, can remain viable for up to 72 hours on inanimate objects after completing its lifecycle in the body of an infected person . Therefore, if the respiratory discharges of a person infected with SARS-CoV-2 come in contact with food, the contaminated food items can theoretically become a temporary carrier if touched by another person that later touches his/her nose, eyes, or mouth without first washing or sanitizing hands .
Food handler (FHs) play an essential role in food safety and in the spread of FBDs because they can introduce pathogens into food served to the patients in the production, processing, distribution, and/or preparation stage. Therefore, well-developed, and validated instruments are needed for assessing the food safety practices adopted by the FHs in healthcare facilities . If a questionnaire of an unknown validity or reliability was used, it would be hard to determine whether the findings were accurate .
Nevertheless, accumulated knowledge about the evaluation of food safety awareness of the food service staffs in hospitals in the COVID-19 pandemic is quite limited so far, and to our knowledge, there is paucity of validated survey instruments that can be adopted for this purpose. Hence, the study was focused to develop and validate an easy to administer and concise tool that will help stakeholders and researchers to assess, measure, and understand key areas within food safety, which is especially important in the COVID-19 era, as well as to increase awareness that will help hospitals by providing the highest possible quality of food service while reducing the risk of patients contracting FBDs.
Materials and Methods
This study was conducted across three sequential phases, comprising instrument development, validation, and translation, as shown in Figure 1. The study was approved by the Research Ethics Committee of the King Abdulaziz University, Saudi Arabia (approval No. HA-02-J-008). The study adopted a structured, self-administered questionnaire to get data from the participants and informed consent was obtained from all participants. The study was carried out from Jan to Apr 2022 in hospitals Jeddah, Saudi Arabia. A cross sectional study using a questionnaire was adopted. All methods were performed in accordance with the relevant guidelines and regulations. Several approaches were adopted when developing a comprehensive instrument, including a review of current regulations and relevant literature, and conducting focus groups and expert interviews. In this study, instrument development was conducted across three stages, as explained below. The factors considered for this instrument were based on the food safety regulations during the COVID-19 pandemic, focusing on the four most significant factors to be controlled to prevent foodborne diseases (clean, separate, cook, chill). For this purpose, Food and Drug Administration (FDA), United States Department of Agriculture (USDA), and Centers for Disease Control and Prevention (CDC) guidelines, as well as the Saudi Arabia Ministry of Health (MOH) guidelines were examined . In addition, pertinent items from other published studies were incorporated into the preliminary questionnaire .
The first draft of the questionnaire was prepared in English including 127 items under four sections: demographic information, and KPPs related to personal hygiene, food poisoning, cross-contamination, preparation, storage, and cooking in healthcare facilities. Section one (demographic) included seven demographic items (gender, age, education level, working experience, and food safety training courses, types of training courses, and position). Section two (knowledge) included 52 multiple-choice items (42 related to general food safety knowledge and 10 pertaining to food safety knowledge during the COVID-19 pandemic). These items focused on cross-contamination, diseases that require restriction or exclusion from working in or around food preparation area, personal hygiene, temperature control, general food safety rules, and other food safety rules in place during the COVID-19 pandemic. Section three (perceptions) included 29 statements (19 to assesses general food safety perceptions and 10 to assess food safety perceptions during the COVID-19 pandemic) rated on a 5-point Likert scale (Strongly disagree = 1, Disagree = 2, Neither agree nor disagree =3, Agree = 4, and strongly agree =5). Section four (practices) comprised of 39 questions (20 to assesses general food safety practices and 19 to assess food safety practices during the COVID-19 pandemic) rated on a 5-point Likert scale (Never = 1, Rarely = 2, Sometimes = 3, Often = 4, and always = 5). This section included questions pertaining to personal hygiene, temperature control, cross-contamination prevention, cleaning, storage, and right steps to store and display foods.
Three small focus group discussions were conducted. The first one included 10 adult members of general public of diverse educational levels, as described by Chopra et al. . The second FGD was held with 10 FSS at different training levels, all of whom were responsible for food handling in healthcare facilities. Both FGDs were guided by a facilitator. As described by Chopra et al. the third FGD involved eight experts recruited from the food and nutrition departments of different universities. Based on their extensive expertise in the field, they were invited to review the overall instrument, as well as suggest addition, removal or rewording of certain items.
Face validity refers to the extent of which a test appears to measure what it is intended to measure , while the term “content validity” refers to the extent of which the items in a questionnaire are representative of the entire theoretical construct the questionnaire is designed to assess . In this study, content and face validity assessments were performed on the English version of the questionnaire. Twenty experts in the field were recruited from hospitals’ Food Service Departments in Jeddah and the Department of Food and Nutrition Science at King Abdulaziz University, and Tabuk University for this purpose. All experts had more than five years of work experience, were well versed in English, and were provided with detailed information regarding the research process and their role. Ten experts were responsible for assessing the face validity as well as language appropriateness, format, reasonableness, readability, consistency, and logical sequence of items.
Content validity was evaluated by the remaining 10n experts by comparing the content of each question and carefully considering question type and construction. In this process, the experts were asked to rate the necessity of each question using the 3-point Likert rating scale proposed by 1 = not necessary; 2 = useful but not necessary; and 3 = essential. The content validity ratio was computed for each questionnaire item based on the following formula developed by :
Where:
ne = number of experts indicating that a measurement item is essential, and
N = total number of experts that rated the item.
In Preliminary pilot testing phase, quantitative methods were utilized for establishing the construct validity and reliability of the questionnaire. The preliminary version of the questionnaire was pilot tested by administering it to 40 randomly selected hospital staff members responsible for food handling. All participants were briefed about the purpose of the study and instructed to respond based on their work practices in food service facilities. Those who agreed to participate provided their written informed consent prior to completing the questionnaire. No monetary compensation was given for participation.
As the 62 knowledge questions were in multiple choice format, descriptive statistics such as frequencies and percentages were used to evaluate the knowledge of food safety among FSS.
The internal consistency of the scale questions (24 items for perceptions, and 25 items for practices) was assessed by using Pearson’s correlation. The internal consistency is the extent to which the items from a measure represent the variable they are intended to measure. Correlation coefficients used to evaluate the internal consistency between the survey items and the factors to which they belong to (perceptions and practices regarding food safety among food service staff in general and during COVID-19), which is the correlation between each statement and the total of the factors where it belongs to .
The reliability of the scale questions (24 items for perceptions, and 25 items for practices) was assessed by using Cronbach’s alpha, as it is the most common measure of the reliability of scales involving Likert-type questions that have latent variables (hidden or unobservable variables). Cronbach’s alpha is a measure used to assess the reliability of a set of test items to determine how closely related this set of test items are as a group .
In Translation of tools/instruments phase, the final version of the English version of the questionnaire was translated by two translation teams. The translation teams were formed to ensure that the documents translated from the source language (English) into the target language (Arabic) are equivalent in terms of semantics, concepts, and norms, as well as being trustworthy, comprehensive, accurate, and culturally appropriate. According to the Census Bureau’s Guideline for the Translation of Data Collection Instruments and Supporting Materials, the translation process followed five steps, denoted as preparation, translation, pretesting, revising, and documentation .
Each of the two translation teams consisted of a bilingual subject matter expert researcher, and translators who have the necessary skills, knowledge, and professional experience in questionnaire translation. These teams worked separately before comparing their work to identify any ambiguities and discrepancies in words, sentences, and meanings, and settle on a single version that incorporates the best aspects of the independent translations .
In preparation for translation step, each translation team was provided with a statement of work that details the objective of the translation, the intended audience, the mode in which the instrument will be administered (self-administered or interviewer-administered data collection), the target language, and the level of formality. In addition to the text designated for translation, the translation teams received all documentation that would be useful in performing the translation, such as the definitions of terms or concepts used in the wording of the questions . Two forms-“criteria for achieving a good translation (Appendix A)” and “translation validation form (Appendix B)”-were adopted from the Census Bureau’s “Translation of data collection instruments and supporting materials” for this study .
The translation step consisted of a direct translation from the source language (English) to the target language (Arabic). Two separate translator teams performed the translation, as described above. According to the criteria recommended by the Census Bureau’s ‘Guideline for the translation of data collection instruments and supporting materials; to achieve the goals of a good translation, both teams were familiar with the concepts in the questionnaire, such as: Who is the target population, including their level of education? Why is the document needed? In what social setting will the document be used? What is the mode of data collection? What is the manner of delivery (formal, informal)? All comments and perspectives concerning the questionnaire were recorded on a form prepared for this purpose (Appendix C), and then the researchers and translation teams discussed and revised the final translated version based on their findings
In Pretesting of the translated questionnaire, accordance with the protocol outlined by , a qualitative concurrent cognitive interview technique was used to pretest the translated version of the questionnaire in this study. The cognitive interview protocol was designed to evaluate the fluency and appropriateness of the translated materials. The probes examined the comprehension of key terms in the questions as well as the overall comprehension of the items (Appendix D). This technique consists of verbal probes that enable researchers to analyze in depth how survey respondents understand the questions (e.g., “Can you explain in your own words what this question means to you?”). This allows participants to rephrase the questions in their own words immediately after answering them, allowing researchers to determine whether participants fully comprehend the questions .
After completing the translation process as described previously, the researchers asked ten randomly selected target participants to verbally explain the meaning of each item and its corresponding response. All discrepancies between the original and translated meanings were recorded by the researchers and discussed with the translation teams so that the final version could be revised. This procedure was repeated multiple times to finalize the translated questionnaire and to ensure that the translated items convey the same meaning as their original equivalents and that the translated questionnaire does not lead to misinterpretation .
Revision is a necessary and integral part of the translation process that continues until the translation is finalized. As described by , in this study, the first revision was performed following the review of the initial translated document and was conducted again after the pretest. The translation team reviewed and revised the questionnaire based on the pretest results and by comparing source-language and target-language definitions and concepts. Adjudication of disagreement between translators was achieved by critical review of the comments provided by participants via cognitive interview/debriefing (Appendix D) before finalizing the translated documents .
For the preparation documentation step, translator teams received a written specification containing all relevant documentation for performing the translation, as outlined earlier . For the translation step, a numbering system for tracking different versions was developed. All comments, perspectives, revisions, and decisions were recorded and documented on the translation teams’ comments and perspectives form (Appendix C), and then the preliminary translation version was revised.
The cognitive interview protocol was designed for the pretesting step to evaluate the fluency and appropriateness of the translated materials (Appendix D). The probes examined the comprehension of key terms in the questions as well as the overall comprehension of the items. Before finalizing the translation, all verbal responses were recorded and discussed with the translation teams in order to be modified.
During the revision process, source-language and target-language definitions and concepts were compared to ensure that the translated version has the same meaning as the SLQ. The word definition list was utilized by translation teams and interviewers when conducting interviews with the selected respondents (Appendix F and G).
Figure 1. Flow chart of the process adopted when developing the survey instrument.
The statistical package for social sciences (SPSS version 25) was used for data analysis. Cronbach’s alpha was calculated to assess the reliability of the questionnaire, while internal consistency was assessed via Pearson’s correlation. Frequencies, percentages, and mean scores were also calculated for descriptive results.
Data availability: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Results
During the first FGD conducted with 10 members of the general public, questionnaire items were discussed to assess their understanding of the topics, and to obtain their feedback regarding the clarity of the questions.
The second FGD was held with 10 FSS at different training levels who were responsible for food handling in healthcare facilities. The purpose of this meeting was to determine the clarity of the questionnaire items and their relevance with respect to the food safety rules that should be followed in healthcare facilities. Based on these discussions, it became evident that some words and phrases such as “cross-contamination,” “temperature abuse,” and “temperature danger zone” needed to be explained in the questionnaire. In addition, the question “At what temperature do pathogens best grow?” was replaced by “Which of the following is considered the ‘temperature danger zone’?”
The third FGD was held with eight experts in the field, who suggested modifying 11 items by stating the type of potential hazard (biological, chemical, or physical) that might be associated with specific questionnaire items. In addition, items 47-55 pertaining to diseases (which require restriction or exclusion from working with food or around food preparation area) were modified to add a list of different diseases, requiring that the respondents indicate those that require reporting to the responsible supervisor. Moreover, 20 duplicate or impertinent items were eliminated (10 from knowledge, three from perceptions, and four from practices section). Thus, the second draft of the questionnaire, comprising of 118 items, some of which were modified, was subjected to face and content validity assessments, as outlined below.
Face validity: For face validity, expert feedback was taken into consideration and some words were rephrased into lay terms or explained (e.g., “food handlers” was changed to “food handlers such as chefs and food preparation area workers”), and “I don’t know” option was added to the multiple-choice constructs.
Three further items were revised or rephrased because they were considered insufficiently understandable by the experts. Thus, Item 81 “Color coding in cutting boards equipment, and utensils, such as knives, will reduce cross-contamination” was replaced with “Encoding the colors of cutting boards, equipment and utensils such as red color use for red meat and green color for vegetables, reduces cross-contamination.” In addition, Item 25 “Cooking food to less than 74 °C for 15 seconds” was replaced by “The internal temperature when cooking does not reach 74 °C (for at least 15 seconds)” and Item 85 “Food handlers can be a source of foodborne diseases” was replaced by “Food handlers such as chefs and food preparation area workers generally can be a source of foodborne diseases.”
As the evaluation of the face value of the questionnaire confirmed that no items needed to be deleted, all 118 items remained.
Content validity: Content validity was expressed as the Content Validity Ratio (CVR), whereby CVRs were calculated for all questionnaire items, and the average CVR score for all items was calculated to determine the total CVR score for the instrument. The minimum CVR needed to retain the item in the questionnaire was determined using the Lawshe table
After Calculation of CVR, 117 of the 118 items received CVR scores greater than 0.62 (the minimum value required for good content validity by the experts). The remaining item (which received CVR = 0.4) was revised by replacing “Leaving food inside the temperature danger zone (between 5 °C and 60 °C) for more than 2 hours is unsafe” with “It is unsafe to leave food inside the temperature danger zone (between 5 °C and 60 °C) for more than 2 hours.” Following this revision, a total CVR of 0.96 was obtained for the instrument, indicating good overall CVR.
The second draft of the questionnaire was pilot tested on 40 respondents to assess the construct validity and thus ensure internal consistency. In addition, descriptive statistics were calculated for all non-scaled items.
Only scaled statements were included in validity testing, which involved calculation of Pearson’s correlation coefficients, and the results are reported in Table 1. As the correlation coefficients for all items (except one) were statistically significant (p < 0.01), the problematic item was excluded.
The correlation is significant at the 0.05 level.
**Correlation is significant at the 0.01 level
Only scaled items were subjected to reliability testing, and the obtained Cronbach’s alpha values are reported in Table 2, whereby 0.7 or higher values were considered to indicate good reliability . As can be seen from the results, the scales evaluating the food safety perceptions and practices among food service staff are reliable, as the corresponding Cronbach’s alpha was 0.875 and 0.830, respectively. On the other hand, Cronbach’s alpha for the food safety perceptions (0.712) and practices (0.727) among food service staff during COVID-19 were somewhat lower, but the scales were still acceptable. The overall Cronbach’s alpha (0.914) indicated that the reliability of the entire instrument was excellent.
Discussions
Hospital food services are crucial to patient care . Since the COVID-19 outbreak, food safety rules have become even more essential, as food handlers can spread the virus by coughing, speaking, breathing, sneezing, or even singing. All these activities can create infectious aerosols that may contain pathogens that then transfer to the surrounding air and objects, thereby impacting patients, customers, and staff . The questionnaire developed in this study was based on significant aspects of food safety in healthcare facilities. A unique feature of the developed questionnaire is that it evaluates food safety knowledge, perceptions, and practices among food service staff in hospitals during the COVID-19 pandemic.
To facilitate questionnaire development, pertinent literature was consulted , along with the food safety regulations during COVID-19 released by the USDA, MOH, CDC, and FDA, focusing on the significant factors (clean, separate, cook, chill) to be controlled to prevent foodborne diseases.
The methodology used in this study when developing, translating, and validating the food safety survey instrument was based on the guidance provided by , as these authors developed similar instruments to assess hospital food service staff knowledge, perceptions, and practices during the COVID-19 pandemic.
According to , a focus group discussion is a way to bring together people that have certain traits in common to talk about a particular subject of interest. These group discussions allow researchers to clarify, elaborate, and better understand the ideas and viewpoints of their target group. As they can also reveal potential issues with questionnaire design and stimulate new ideas and concepts , they are used in different disciplines . In this study, three FGDs were conducted, allowing researchers to assess the instrument’s clarity and relevance from the perspective of the general public, food service staff, and experts. Their views were considered when revising the questionnaire. Its content validity was also assessed using the Lawshe method and the CVR of 0.96 indicated good content validity.
The first draft of the questionnaire was pilot tested by administering it to randomly selected 40 hospital food service staff. As explained by , the main objective of the pilot test is to evaluate the research tools, verify the degree of ease in its application, and the adequacy of the terms, as well as to facilitate comprehension by the evaluator on the items and sub-items After the pilot study, the revised questionnaire had 115 items.
This version was subjected to descriptive analysis, which confirmed that the majority of respondents were well-versed in all subjects addressed in the survey. Similar findings were established by among 163 food service staff from 10 hospitals in Al Madinah, Saudi Arabia. The results also concurred with those reported by based on a survey of 120 food handlers working in companies that provide food to hospitals in Beirut, Lebanon.
It is worth noting that found that most of the food handlers did not know the minimum internal cooking temperature for different types of foods, indicating that the instrument developed as a part of this study would be a useful tool for assessing their general food safety knowledge. Similarly, noted that 76.2% and 70.6% of 235 food handlers surveyed in 29 institutions in Ghana were not aware that salmonella and Hepatitis A are foodborne pathogens, respectively. As who surveyed 532 food service staff in 37 hospitals in Jordan (public, private, and university hospitals) also found that a significant percentage of their respondents lacked adequate knowledge of foodborne pathogens and related symptoms and illnesses, the section in our instrument related to these topics was highly relevant. We also addressed knowledge of cross-contamination, which was found inadequate in previous studies .
Our instrument was assessed for internal consistency, and the findings confirmed that it has been achieved, as the overall Cronbach’s alpha reliability of all instrument scales (0.914) exceeds the 0.7 threshold
Finally, as the instrument was initially developed in English, the translation to Arabic was performed by experts to ensure that the Arabic translations retained the original meaning. However, on the advice of the Census Bureau expert panel, backward translation was not performed, as it frequently does not result in instruments of acceptable quality for data collection .
Conclusion
The paucity of validated survey instruments that can be adopted by healthcare facilities to evaluate food safety status among FSS who provide food to vulnerable hospitals patients emphasized the need of developing and validating an instrument for this purpose. In this study, a survey developed, tested, and validated to cover all the important aspects for assessing KPP of food safety among FSS. The developed instrument is reliable, valid, concise, and easy to administer tool that will help stakeholders and researchers to assess, measure, and understand key areas within food safety in healthcare facilities, which is especially important in the COVID-19 era. Such instruments will increase awareness and help hospitals provide the highest possible quality of food service, while reducing the risk of patients contracting FBDs. This instrument is recommended to be used in healthcare facilities in normal cases or during FBDs outbreak or health crises such as COVID-19 pandemic, as it covers important aspects to be evaluated and emphasized during food production in healthcare facilities.
6. Reference
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