Survey on hygiene and food safety among kitchen staff in preschools in Podgorica, Montenegro

This cross-sectional behavioural study was conducted from May to July 2023 in all public and private preschools in Podgorica, Montenegro, encompassing 48 preschool kitchens and all 113 kitchen employees. The only exclusion criterion was absenteeism due to illness or other work-related reasons; however, all employees (100 %) were included in the study.

Data were collected using a structured questionnaire and an observation checklist. The questionnaire consisted of 62 closedended questions, covering sociodemographic characteristics (8 questions), food safety knowledge (22 questions), attitudes (12 statements), and self-reported practices (20 statements). The design of the questionnaire and observation checklist was based on a literature review and modified to align with Montenegrin regulations (11, 13–18, 24–27). More specifically, the knowledge questions were: focused on personal hygiene, time and temperature control, crosscontamination, food storage, and equipment hygiene. Responses were scored as “Yes” (1), “No” (0), and “I don’t know” (0). Attitude statements: rated on a five-point scale from “strongly disagree” (1) to “strongly agree” (5), with positive responses scoring “1” and negative or neutral responses scoring “0”. Self-reported practices: rated on a scale from “never” (1) to “always” (5), with the responses “often” or “always” scoring “1” and less frequent responses scoring “0”.

Results were converted into percentages and categorized as good/positive (80–100 %), moderate/satisfactory (50–80 %), or poor/negative (0–50 %) based on the Bloom cut-off point (10). Negative responses were transformed into positive ones for scoring consistency.

The researcher and three trained assistants observed the workflow, hygiene practices, and attitudes of the studied kitchen staff during different stages of the process: meal preparation, cooking and handling, food service, and post-service tasks such as cleaning. The same scoring system was applied to both the observation and self-reported assessments of food-handling practices, with identical questions for evaluation.

Data collection was anonymous, with each participant completing the questionnaire only once. Practices were monitored by observing each kitchen staff member individually, as they typically work in small groups at different locations across the city. This approach allowed for a focused assessment of specific activities, such as meal preparation and hygiene practices, as well as a comparison of individual performance with self-reported practices.

A pilot study with 15 participants from a preschool outside Podgorica was conducted to test the clarity and reliability of the questionnaire and achieved a Cronbach’s alpha coefficient of 0.75. Participants provided informed consent, and ethical approval for the study was obtained from the Institute for Public Health of Montenegro (No. 01-3790, 28 April 2023) and the Ministry of Education (No. 01-011/23-3394/2, 3 May 2023).

Data were analyzed using SPSS, version 22.0 (IBM Corp., 2013, Armonk, NY, USA). Mean values, standard deviations, and response frequencies were calculated for each variable. Both parametric and non-parametric analyses were used. Pearson and Spearman correlation coefficients, Mann-Whitney, and Kruskal-Wallis tests examined the comparison and correlation of knowledge, attitudes, and practices of food handlers. Statistical significance was set at p<0.05.

The socio-demographic characteristics of 113 respondents are summarized in Table 1. The surveyed group was predominantly female (98.2 %), with most employees in the 35–44 (34.5 %) and 45–55 (33.6 %) age groups. The average age was 43.6±10.3 years, and the average work experience was 12.6±8.5 years. Most respondents (88.5 %) completed secondary school, while only 2.7 % completed primary school alone, which is compulsory in Montenegro. More than five years of work experience was reported by 78 % of respondents. Training in safe food handling was attended more than once by 54.9 % of respondents, once by 21.2 %, and never by 23.9 %. The majority of respondents (83.2 %) knew that the hazard analysis and critical control points management system (HACCP) was implemented in their institution, but only 14.3 % had a “hygienic minimum” course certificate, which had been obligatory since June 2021 (28).

The average knowledge score among food handlers was 77.25±2.69 %, ranging from 19.4 to 95.4 % (Table 2). Personal hygiene knowledge was high (89.76±2.69 %), although 18 % of respondents were unaware that hands should be washed before using gloves. Most respondents (97.2 %) knew not to use the same gloves for handling fruit and meat and 89.7 % understood that hair can contaminate food. Knowledge about time and temperature control was lower, with a mean score of 69.60±0.91 %. Half of the respondents (50.9 %) incorrectly answered questions about defrosting meat with water from a boiler or at room temperature overnight and 11.5 % were unsure. While 79.2 % recognized that freezing slows bacterial growth, 71 % correctly identified the optimal bacterial growth temperature range (5–61 °C). Cross-contamination knowledge was moderate (71.84±0.85 %), while equipment hygiene knowledge had the lowest score (68.48±1.04 %), with responses ranging from 19.4 to 91.7 %.

The overall mean score for food safety attitudes was 95.72±4.53 % (Table 3). Proper food management is considered a significant part of the responsibility of food handlers, as agreed by 99.1 % of respondents. All of the respondents (n=113) confirmed that it was important to maintain personal hygiene during work, keep nails short and without nail polish, wash hands before handling food, take sick leave if they have a foodborne illness, and agreed that training on safe handling of food is essential to them. As many as 93.8 % of respondents acknowledged that food handlers can be the source of foodborne outbreaks. A high percentage of respondents (>95 %) agreed that expired food should not be consumed, even if there is no change in its appearance and smell and that people with cuts on their hands should not touch unwrapped food. Furthermore, 96.5 % agreed that how we store food affects its safety.

Our observation of food handling practices revealed discrepancies between the self-reported and observed behaviours (p<0.05) (Table 4). The overall mean observed practice score was 64.65±27.73 %, which is lower than the self-reported scores. While over 99 % claimed they washed hands properly before handling food, eating, and after using the bathroom, only 18.6, 49.6, and 83.1 % were observed doing so, respectively. Although 96.6 % reported not touching their noses during work, only 23.0 % adhered to this. With regard to smoking, 98.3 % self-reported not smoking, but observation showed a 93.8 % adherence. While 92 % acknowledged not working while stricken with a confirmed food-borne infection and 80.5 % reported not working when ill, only 57.5 % adhered to this. Additionally, 84 % reported not working with cuts, but only 54.1 % truly did not. Compliance with short nails was reported by 96.4 % but observed in 91.2 %. Although 96.6 % reported drying hands with disposable towels, only 66.3 % were observed doing so. While 91.6 % reported regularly changing gloves, only 14.3 % did so. Lastly, 95.3 % reported always cleaning surfaces in contact with food, but only 56.3 % were observed doing so.

The analysis of sociodemographic characteristics showed no significant difference in knowledge levels between respondents from public and private preschools (p=0.96, p>0.05). A weak positive correlation was found between knowledge and work experience (r=0.20, p=0.03), indicating that more work experience corresponds to higher knowledge (p<0.05).

A significant difference in knowledge was found between trained (M=35.14, SD=1.70) and untrained (M=32.54, SD=3.18) respondents (p=0.01, p<0.05). Those with higher education levels and those who attended the “hygienic minimum” course had higher knowledge scores (p<0.05).

Respondents with previous work experience in canteens, restaurants, and hotels had better knowledge about crosscontamination compared to those with experience in food production facilities or no prior employment (p<0.05). Repeated training also improved knowledge about food preservation (p<0.05). Higher education and HACCP implementation were associated with a better understanding of equipment hygiene (p<0.05).

Sociodemographic characteristics did not significantly influence attitudes or self-reported practices, except for the positive impact of possessing a food safety certificate (Table 5).

The relationship between knowledge, attitudes, and self-reported practices is shown in Table 6. A weak positive correlation was found between knowledge and attitudes (r=0.19, p=0.04), indicating that good knowledge was associated with positive attitudes (p<0.05). However, no relationship was found between knowledge and selfreported practices, or between attitudes and self-reported practices (p>0.05). This suggests that good knowledge and attitudes do not necessarily lead to good practices.

A multiple linear regression analysis was conducted to predict self-reported food hygiene practices based on knowledge and food safety attitudes. The model significantly predicted practices (F=73.307, p<0.00, R²=0.53), explaining 53 % of the variance. The self-reported practice score increased by 0.35 with the knowledge score and 0.55 with the attitude score. This indicated that, while knowledge and attitudes were good predictors of self-reported practices, attitudes are the stronger predictor (Table 7).

The results from observations provide a realistic picture of the work environment and hygiene practices. However, as regulations do not allow unannounced access to public kitchens, visits were prearranged, potentially leading to better hygiene practices being observed than in normal circumstances.