📄 medicine

Hygienic compliance and food safety knowledge, attitudes and practices of food handlers in food establishments in Jalalabad city, Nangarhar province, Afghanistan

This study of 384 food handlers in Jalalabad, Afghanistan, reveals that while food safety knowledge, attitudes, and practices are generally moderate to good, the overall hygienic status of food establishments is poor, highlighting a critical need for enhanced monitoring and comprehensive training programs to improve compliance.

Original authors: Sayed Attaul haq Banuree, Hayatullah Takal, Najibullah Rahimi, Fazalakbar Khalili, Mujiburahman Sadat, Sayed Ziaulhaq Banuree, Ezatullah Arab

Published 2026-07-14

📖 5 min read🧠 Deep dive

CC BY 4.0

Original authors: Sayed Attaul haq Banuree, Hayatullah Takal, Najibullah Rahimi, Fazalakbar Khalili, Mujiburahman Sadat, Sayed Ziaulhaq Banuree, Ezatullah Arab

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Imagine the bustling city of Jalalabad as a giant, hungry kitchen where thousands of people are constantly cooking up meals for the masses. In this kitchen, there are 74 different "food stations" (restaurants, hotels, wedding halls, and juice shops) and 384 hungry workers (food handlers) keeping the gears turning. A team of researchers decided to step in and take a peek behind the curtain to see how clean the kitchen is and how well the workers know the rules of the game.

The Cleanliness Score: A Mixed Bag
Think of the cleanliness of these food stations like a report card. The researchers gave the whole city an average score of 60.92 ± 16.59%. That's a "C" grade—right in the middle of the pack, but definitely not an "A."

Here's the twist: some stations were shining stars, while others were a bit messy. The wedding and mass gathering halls were the perfect students; every single one of them (100%) got a "Good" rating for hygiene. Hotels and hotel restaurants also did pretty well. But the fast-food places were the ones struggling, with 60.0% of them falling into the "Poor" category. It's like a fancy banquet hall being spotless while a quick burger joint is a bit of a disaster zone.

The researchers found that while the kitchens had good ventilation and waste bins (100% of them!), they were missing some crucial safety gear. For instance, 97.3% of the places didn't have a septic tank for liquid waste, and a whopping 97.3% of the workers weren't wearing protective gear like gloves or hairnets during the interview. It's like having a super-fast car but forgetting to put on a seatbelt.

The Workers' Brainpower: Knowledge, Attitude, and Action
The researchers also asked the 384 workers three big questions: What do you know? How do you feel about it? And what do you actually do?

Knowledge (What they know): The workers scored a 61.33 ± 6.96%. This is a "Moderate" level. They were great at the basics, like knowing you should wash your hands (Personal Hygiene: 83.54%) and recognizing the symptoms of getting sick from bad food (77.58%). However, they hit a wall with the "science stuff." When asked about specific germs (foodborne pathogens), their score plummeted to a tiny 2.23 ± 9.56%. It's like knowing you shouldn't touch a hot stove, but having no idea why the fire burns or what kind of fire it is.
Attitude (How they feel): This was the highlight! The workers scored a 78.29 ± 15.08%, which is a "Good" level. Most of them agreed that food safety is super important and that they have a responsibility to keep things clean. They felt the right way about the job, even if they didn't always know all the technical details.
Practice (What they actually do): This is where the rubber meets the road. The score here was 60.91 ± 13.46%, landing back in the "Moderate" zone. While many workers said they always wash their hands after touching raw meat (62.2%), fewer were consistent with other habits. For example, only 59.1% always used separate equipment for raw and cooked food. It's the difference between saying "I'll clean my room" and actually picking up the socks.

The Secret Sauce: Who Does It Best?
The study found that who you are matters. The researchers discovered that older workers (36+ years), those with higher education (like a bachelor's degree), and those with more experience (over 10 years) tended to know more and do better. Cooks and managers generally scored higher than dishwashers or waiters.

Interestingly, the paper explicitly ruled out one thing that people often assume helps: formal food safety training. The data showed that whether a worker had attended training or not did not make a significant difference in their knowledge or practices. The researchers suggest this might be because the training they received was too short, too boring, or didn't include enough hands-on practice. So, just showing up to a class didn't automatically make them food safety experts.

The Connection: A Chain Reaction
The researchers found a strong link between these three areas. They measured the connection and found that if a worker's knowledge goes up, their attitude and practices tend to go up too. It's like a domino effect: knowing the rules helps you care about them, and caring about them helps you follow them. Specifically, knowledge and practice had a strong connection (r = 0.47), suggesting that teaching the workers more about the "why" and "how" of food safety could be the key to unlocking better habits.

The Bottom Line
The paper concludes that while the food handlers in Jalalabad have a good heart and a decent understanding of the basics, the actual cleanliness of the kitchens and the depth of their scientific knowledge need a boost. The "C" grade for hygiene and the low score on germ knowledge suggest that the city needs more than just a quick pep talk. The researchers recommend regular check-ups of the kitchens and better, more practical training programs that focus on the missing pieces—especially the science of germs and proper storage. Until then, the kitchen is safe enough for a quick bite, but it's not quite ready for a five-star Michelin review.

Technical Summary: Hygienic Compliance and Food Safety KAP in Jalalabad, Afghanistan

Problem Statement
Foodborne diseases (FBDs) represent a significant global health burden, causing approximately 600 million morbidities and 42,000 deaths annually, with a disproportionate impact on developing nations and children under five. In the Eastern Mediterranean region, including Afghanistan, the burden is substantial, with 70% of cases attributed to diarrheal diseases caused by pathogens such as E. coli, Norovirus, Campylobacter, and non-typhoidal Salmonella. While Food Service Establishments (FSEs) are responsible for providing safe food and account for approximately 70% of global FBD outbreaks, there is a critical lack of data regarding the hygienic compliance of these establishments and the Knowledge, Attitudes, and Practices (KAP) of their food handlers in Afghanistan. Specifically, no prior studies had investigated these factors in Nangarhar province, necessitating an assessment to inform future interventions.

Methodology
This cross-sectional study was conducted between May 1 and July 25, 2023, in Jalalabad city, Nangarhar province. The study population consisted of 384 food handlers from 74 FSEs, selected via simple random sampling. The sample size was calculated using Cochran's formula, assuming a 50% prevalence rate, a 95% confidence level, and a 5% precision margin.

Data collection utilized a structured, pre-tested questionnaire administered via face-to-face interviews. The instrument, translated into local languages (Pashto and Dari) and validated for reliability (Cronbach's α ≥ 0.7), assessed four primary domains:

Hygienic Compliance of FSEs: Evaluated against 24 criteria (e.g., water supply, waste management, ventilation, PPE usage), scored as present (1) or absent (0).
Food Safety Knowledge: Assessed via 60 criteria across six categories: personal hygiene, cross-contamination prevention, food handling, health problems, foodborne pathogens, and FBD symptoms.
Food Safety Attitudes: Measured using 11 criteria regarding agreement with safety protocols.
Food Safety Practices: Evaluated via 15 criteria on a frequency scale (never to always).

Statistical analysis was performed using SPSS v.23. Descriptive statistics were used for demographic data. Independent t-tests, ANOVA, and non-parametric alternatives (Mann-Whitney U, Kruskal-Wallis) were employed to compare means across groups. Pearson's correlation assessed relationships between KAP variables, and multiple linear regression identified socio-demographic predictors of KAP scores.

Key Results

Hygienic Compliance: The overall mean hygienic status of FSEs was 60.92% ± 16.59%, categorized as "moderate." However, 60.8% of establishments were classified as having "poor" hygienic status. A significant association was found between FSE type and hygiene status ( $\chi^2 = 22.43, P = 0.013$ ). Wedding and mass gathering halls achieved 100% "good" status, as did 51.9% of hotels and 46.7% of hotel restaurants. Conversely, fast-food catering establishments had the poorest performance, with 60.0% rated as "poor." Critical deficiencies included the lack of septic tanks (97.3% absent), non-use of Personal Protective Equipment (97.3% absent), and the absence of separate kitchens (79.7% absent).
Knowledge: The mean food safety knowledge score was 61.33% ± 6.96% (moderate). Knowledge was highest regarding personal hygiene (83.54%) and FBD symptoms (77.58%), but critically low regarding foodborne pathogens (2.23%). Knowledge levels varied significantly across all socio-demographic variables (age, education, income, etc.), except for prior enrollment in food safety training.
Attitudes: The mean attitude score was 78.29% ± 15.08% (good). The majority of handlers (71.4%) exhibited good attitudes. However, specific areas showed weakness, such as the belief that leftovers should be kept in the refrigerator (47.7% agreement) and that leaving cooked food out for over two hours is unsafe (29.4% agreement). Attitudes were significantly associated with all socio-demographic variables.
Practices: The mean practice score was 60.91% ± 13.46% (moderate). While many handlers reported always washing hands after touching raw food (62.2%) and avoiding smoking in production areas (89.6%), adherence to other protocols was inconsistent. Practices were significantly associated with all socio-demographic variables except training enrollment.
Correlations and Predictors: Pearson's correlation revealed significant positive relationships between knowledge and practice ( $r=0.47$ ), knowledge and attitude ( $r=0.18$ ), and attitude and practice ( $r=0.17$ ). Multiple regression analysis identified age, education level, type of responsibility, and FSE type as significant predictors of knowledge. Monthly income and FSE type predicted attitudes. Age, education, income, work experience, responsibility type, and FSE type predicted practices. Notably, enrollment in food safety training was not a significant predictor for knowledge or practices in this dataset.

Significance and Claims
The authors claim this is the first study to investigate the hygienic compliance of FSEs and the food safety KAP of handlers in Jalalabad city and Nangarhar province. The study highlights a dichotomy where food handlers possess moderate-to-good knowledge and good attitudes, yet these do not fully translate into optimal hygienic practices or establishment-level compliance.

The paper concludes that while the hygienic status of FSEs is generally poor, the human element (handlers) shows potential for improvement. The authors assert that the significant positive correlation between knowledge, attitude, and practice suggests that enhancing knowledge levels is a viable pathway to improving attitudes and subsequent practices. Consequently, the study recommends:

Regular monitoring of all FSE types, not just high-performing ones.
Implementation of comprehensive food safety training programs tailored to socio-demographic factors.
Specific focus on weak knowledge domains, particularly foodborne pathogens, followed by food handling and cross-contamination prevention.

The authors acknowledge a limitation regarding generalizability, noting that the study population consisted entirely of male food handlers, as female handlers were not present in the sampled commercial FSEs in this context. They suggest future research should include settings where female handlers are active, such as households and hospitals.

Technical Summary: Hygienic Compliance and Food Safety KAP in Jalalabad, Afghanistan

More like this