Introduction
Food hygiene is an essential matter of public health for protecting or preventing diseases caused by unsafe food due to lack of good quality from production, processing to consumption (Ethiopian Ministry of Health, 2019). Food safety (or food hygiene) is used as a scientific method/discipline that describes the handling, preparation, and storage of food in a manner that prevents foodborne disease (Food Safety Definition and Why Is Food Safety Important, 2018).
According to the World Health Organization (WHO), one in 10 people worldwide suffers from foodborne illnesses, endangering both developed and underdeveloped countries. Consumption of contaminated food poses a significant threat to billions of people worldwide (Fung et al., Reference Fung, Wang and Menon2018). Each year, an estimated 600 million individuals experience illness as a result of consuming food contaminated with harmful agents, leading to a staggering 420,000 fatalities attributed to the disease (Zanin et al., Reference Zanin, da Cunha, de Rosso, Capriles and Stedefeldt2017).
Foodborne diseases have a significant global impact and affect people of all ages, especially children under five years of age. They are more common in developing countries due to a lack of sanitation, a lack of drinking water, contaminated and improper food storage equipment, and a lack of food safety education (Ucar et al., Reference Ucar, Yilmaz, Cakıroglu and Makun2016; Stratev et al., Reference Stratev, Odeyemi, Pavlov, Kyuchukova, Fatehi and Bamidele2017; Lamuka, Reference Lamuka and Motarjemi2014).
Most foodborne illnesses are caused by bacterial, viral, and parasitic infections. Salmonella, campylobacter, enterohaemorrhagic Escherichia coli, and listeria are the most common bacteria causing foodborne infections. Other foodborne diseases caused by intestinal parasites such as Entamoeba histolytic, Giardia lamblia, Taenia species, Ascaris lumbricoide, and Trichuris trichiura are associated with unsanitary food handling (Kendall, Reference Kendall2022; Belhu et al., Reference Belhu, Fissehatsion, Tesfaye, Woldekidan and Desta2020).
Institutional and community food service is an important sector of the food industry. Food consumed in such facilities is considered to be a major cause of foodborne disease outbreaks (Parry-Hanson Kunadu et al., Reference Parry-Hanson Kunadu, Ofosu, Aboagye and Tano-Debrah2016). Foodborne illnesses in facilities with large numbers of people pose a public health concern because outbreaks in these locations can affect large numbers of consumers at the same time. In developing countries, the lack of ensuring proper hygienic food handling practices in these areas is a major concern (Abdul-Mutalib et al., Reference Abdul-Mutalib, Abdul-Rashid, Mustafa, Amin-Nordin, Hamat and Osman2012).
Food handlers are expected to have excellent hygiene practices to reduce cross-contamination and protect consumers from foodborne diseases (Nnebue et al., Reference Nnebue, Adogu, Ifeadike and Ironkwe2014). Poor personal hygiene frequently contributes to foodborne illness which indicates that food handlers’ knowledge and handling practices need to be improved (Akabanda et al., Reference Akabanda, Hlortsi and Owusu-Kwarteng2017). Pooled data studies on the conditions of food and drink establishments have been scanty in sub-Saharan Africa.
Foodborne infections affect the socioeconomic development of these countries. Foodborne bacterial diseases are common in sub-Saharan Africa. Ensuring food hygiene practices contributes to a high level of food safety, the most important aspect of food quality. To protect consumer health, food safety and hygiene are vital (Heman). For this reason, both the European Union and the WHO recommend that community measures such as food safety, food hygiene, and water security be re-evaluated in light of scientific evidence, which is crucial for the prevention of foodborne infections (European Commission, 2018).
Based on our search databases, there is no systematic review and meta-analysis on hygienic food handling practices in sub-Saharan Africa. For this reason, there is a limitation in easy access to compiled documents on hygienic food handling practices and the factors involved. The lack of a pooled study examining the prevalence and factors related to food hygiene practices among food handlers in food businesses represents a significant gap. This review can provide well-organized data that form the start of available research on food handling practices in sub-Saharan Africa.
The objective of this systematic review and meta-analysis was to identify the pooled prevalence of food hygiene practices and associated factors among food handlers working in food establishments in sub-Saharan Africa. What was the status of food hygiene practices at food handlers? And what factors were associated with food hygiene practices among food handlers in sub-Saharan Africa? The results of this study could help governmental and non-governmental organizations to develop and implement effective strategies to improve food hygiene and safety for food handlers.
Methods
The study protocol and registration
The purpose of this systematic review and meta-analysis is to determine the pooled prevalence of food hygiene practices and its factors among food handlers in sub-Saharan Africa. To ensure the accuracy and completeness of the study, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 checklist was used (Liberati et al., Reference Liberati, Altman, Tetzlaff, Mulrow, Gøtzsche, Ioannidis, Clarke, Devereaux, Kleijnen and Moher2009). The review protocol has been submitted to the International Prospective Register for systematic reviews to ensure transparency and accountability.
Searching strategy
A comprehensive search of databases was undertaken using PubMed, Science Direct, African Journal Online, and Google Scholar to find potentially relevant articles focusing on food hygiene practices and related factors among food handlers in sub-Saharan Africa. In addition to the database search, the cited literature listed in the reference of the articles was also manually searched, and the relevant additional articles were identified and included. The search strategy used the Boolean operators ‘AND’ and ‘OR’ to refine the search results. Keywords used in the search included ‘Food’, ‘food handling Practices’, ‘hand hygiene’, ‘food hygiene’, ‘associated factors’, and ‘sub-Saharan Africa’. These search terms were selected based on the PECCO – principles selected to ensure retrieval of relevant articles from the above databases. All searches were limited to papers written in English, and the last search in all databases was performed on 22 November 2023.
Population, exposure, context, condition, and outcomes (PECCO) guidelines
P = Population: The food handlers. E = Exposure: The level of exposure plays a crucial role in influencing the adherence to food hygiene practices by food handlers in sub-Saharan Africa. These factors include food safety training, level of education, medical checkups, and food handler attitudes. C = Context: sub-Saharan Africa. C = Condition: hand hygiene practices.
O = Outcome measurement: The main objective of the research was to assess the prevalence of food hygiene practices. Furthermore, the study sought to investigate the factors that impact safety practices among food processors. This goal was accomplished through the analysis of data from primary studies using odds ratio and binary outcomes.
Inclusion and exclusion criteria
This study included studies that met specific criteria. These criteria included having a population of food handlers, focusing on the prevalence of food hygienic practice and its associated factors. The studies were conducted exclusively in sub-Saharan Africa and were published in English. However, certain primary studies were excluded for various reasons. These reasons included a lack of information on the prevalence of food hygiene practice, unavailability of the full text, low-quality score, inability to access the full text after multiple attempts to contact the corresponding author, and exclusion of narrative reviews, editorials, correspondence, abstracts, or methodological studies.
Data extraction
Using a pretested data extraction format, two researchers (YAA and KAG) extracted all the required data. The first author or research group name, year of publication, study country, study setting, study design, sample size, and status of hand hygiene practice were all extracted. The reviewers independently collected data on factors associated with hand hygiene practices. For the second outcome (factors related to food hygiene practice), the data were extracted in a 2-by-2 table format and the odds ratio for each factor was calculated based on the findings of the original studies.
Operational definitions
Food hygiene practice: food handlers who scored less than the mean value of the score of the practice questions were considered as having ‘poor food hygiene practices’ and those who scored mean and above the mean value of the practice questions were considered as having ‘good food hygiene practice’ (Abdi et al., Reference Abdi, Amano, Abrahim, Getahun, Ababor and Kumie2020).
Food establishment: facilities that provide large groups of consumers with food and drink services such as breakfast, lunch, dinner, or cocktails. These institutions include hotels, cafes and restaurants, cafeterias, and butcher shops (Zeleke et al., Reference Zeleke, Bayeh and Azene2022).
Data analysis
After extraction of all relevant findings in a Microsoft Excel spreadsheet, the data were exported to STATA software version 14 for analysis. The pooled prevalence of food hygiene practice was calculated using a 95% confidence interval. Publication bias was checked by funnel chart and more objectively by Begg and Eggers regression tests, with P < 0.05 indicating possible publication bias. The presence of heterogeneity between studies was checked using the Cochrane Q statistic. This heterogeneity between studies was quantified using I2, in which a value of 0, 25, 50, and 75% represented no, low, medium, and high heterogeneity, respectively. A forest plot was used to visually assess the presence of heterogeneity, which presented at a high-level random effect model was used for analysis to estimate the pooled estimate of food hygiene practice. Sub-group analysis was done by country, study setting, and sampling techniques. A sensitivity analysis was executed to see the effect of a single study on the overall prevalence of the meta-analysis estimate. The findings of the study were presented in the form of text, tables, and figures.
Results
Searching process
This systematic review and meta-analysis included published studies conducted on the prevalence and factors associated with hygienic food handling practices among food handlers in sub-Saharan. A total of 2,448 records were retrieved through electronic database searching. After removing duplicated studies, we obtained 1543 studies selected for screening full titles and abstracts. Of these, 1422 studies were excluded due to title and abstracts, and the remaining 120 articles were assessed for full-text articles. After reviewing the full text, 78 articles were then eliminated because they lacked full titles and abstracts and reported findings. Finally, 42 full-text primary articles were selected for quantitative analysis (Fig. 1).
Figure 1. PRISMA flow chart displays the article selection process for food hygiene practice in sub-Saharan Africa.
Characteristics of included studies
This systematic review and meta-analysis included 42 articles with a total sample size of 12,367 food handlers (Blaise, Reference Blaise2014; Mwove et al., Reference Mwove, Imathiu, Orina and Karanja2020; Fanta et al., Reference Fanta, Azene, Habte, Samson and Kebede2023; Abegaz, Reference Abegaz2022; Oladoyinbo et al., Reference Oladoyinbo, Akinbule and Awosika2015; Werkneh et al., Reference Werkneh, Tewelde, Gebrehiwet, Islam and Belew2023; Negassa et al., Reference Negassa, Anbese, Worku, Areba, Seboka, Debela, Kanno and Soboksa2023; Jumanne & Sophia, Reference Jumanne and Sophia2014; Engdaw et al., Reference Engdaw, Tesfaye and Worede2023; Tuglo et al., Reference Tuglo, Agordoh, Tekpor, Pan, Agbanyo and Chu2021; Makhunga et al., Reference Makhunga, Macherera and Hlongwana2023; Teferi et al., Reference Teferi, Sebsibe and Adibaru2021; Marutha & Chelule, Reference Marutha and Chelule2020; Mbombo-Dweba et al., Reference Mbombo-Dweba, Mbajiorgu and Oguttu2022; Azanaw et al., Reference Azanaw, Gebrehiwot and Dagne2019; Ndoli & Nicholas, Reference Ndoli and Nicholas2019; Alemu et al., Reference Alemu, Motbianor, Birhanu and Birara2023; Nonga et al., Reference Nonga, Simforian and Ndabikunze2014; Tegegne & Phyo, Reference Tegegne and Phyo2017; Akabanda et al., Reference Akabanda, Hlortsi and Owusu-Kwarteng2017; Alemayehu et al., Reference Alemayehu, Aderaw, Giza and Diress2021; Ituma et al., Reference Ituma, Onwasigwe, Nwonwu, Azuogu and Eze2019; Bulto et al., Reference Bulto, Juta, Demissie, Woldemichael, Werku and Berkessa2022; Odipe et al., Reference Odipe, Raimi, Deinkuro, Funmilayo, innocent Edewor, Lateefat and Fadeyibi2019; Selepe & Mjoka, Reference Selepe and Mjoka2018; Teferi, Reference Teferi2022; Adane et al., Reference Adane, Teka, Gismu, Halefom and Ademe2018; Thandi & Campbell, Reference Thandi and Campbell2011; Dagne et al., Reference Dagne, Raju, Andualem, Hagos and Addis2019; Abdalla et al., Reference Abdalla, Suliman and Bakhiet2009; Nkhebenyane & Lues, Reference Nkhebenyane and Lues2020; Teffo & Tabit, Reference Teffo and Tabit2020; Bigson et al., Reference Bigson, Essuman and Lotse2020; Zeleke et al., Reference Zeleke, Bayeh and Azene2022; Tessema et al., Reference Tessema, Gelaye and Chercos2014; Tamiru et al., Reference Tamiru, Bidira, Moges, Dugasa, Amsalu and Gezimu2022; Mariam et al., Reference Mariam, Mambosasa and Emmanuel2022; Yenealem et al., Reference Yenealem, Yallew and Abdulmajid2020; Matumba et al., Reference Matumba, Monjerezi, Kankwamba, Njoroge, Ndilowe, Kabuli, Kambewa and Njapau2016; Okojie et al., Reference Okojie, Wagbatsoma and Ighoroge2005; Isara et al., Reference Isara, Isah, Lofor and Ojide2010; Omemu & Aderoju, Reference Omemu and Aderoju2008). All included studies were cross-sectional studies. Of these, 24 were community-based cross-sectional studies, while the remaining 18 studies were institutionally conducted. Of these cross-sectional studies, 32 used probability sampling, seven studies were non-probability studies, and three studies used both methods. The earliest study was conducted in 2005 (Okojie et al., Reference Okojie, Wagbatsoma and Ighoroge2005), and the most recent five articles (Fanta et al., Reference Fanta, Azene, Habte, Samson and Kebede2023; Werkneh et al., Reference Werkneh, Tewelde, Gebrehiwet, Islam and Belew2023; Negassa et al., Reference Negassa, Anbese, Worku, Areba, Seboka, Debela, Kanno and Soboksa2023; Engdaw et al., Reference Engdaw, Tesfaye and Worede2023; Alemu et al., Reference Alemu, Motbianor, Birhanu and Birara2023) were published in 2023. Eighteen studies conducted in Ethiopia (Fanta et al., Reference Fanta, Azene, Habte, Samson and Kebede2023; Abegaz, Reference Abegaz2022; Werkneh et al., Reference Werkneh, Tewelde, Gebrehiwet, Islam and Belew2023; Negassa et al., Reference Negassa, Anbese, Worku, Areba, Seboka, Debela, Kanno and Soboksa2023; Engdaw et al., Reference Engdaw, Tesfaye and Worede2023; Teferi et al., Reference Teferi, Sebsibe and Adibaru2021; Azanaw et al., Reference Azanaw, Gebrehiwot and Dagne2019; Alemu et al., Reference Alemu, Motbianor, Birhanu and Birara2023; Tegegne & Phyo, Reference Tegegne and Phyo2017; Alemayehu et al., Reference Alemayehu, Aderaw, Giza and Diress2021; Bulto et al., Reference Bulto, Juta, Demissie, Woldemichael, Werku and Berkessa2022; Teferi, Reference Teferi2022; Adane et al., Reference Adane, Teka, Gismu, Halefom and Ademe2018; Dagne et al., Reference Dagne, Raju, Andualem, Hagos and Addis2019; Zeleke et al., Reference Zeleke, Bayeh and Azene2022; Tessema et al., Reference Tessema, Gelaye and Chercos2014; Tamiru et al., Reference Tamiru, Bidira, Moges, Dugasa, Amsalu and Gezimu2022; Yenealem et al., Reference Yenealem, Yallew and Abdulmajid2020), six studies in Nigeria (Oladoyinbo et al., Reference Oladoyinbo, Akinbule and Awosika2015; Ituma et al., Reference Ituma, Onwasigwe, Nwonwu, Azuogu and Eze2019; Odipe et al., Reference Odipe, Raimi, Deinkuro, Funmilayo, innocent Edewor, Lateefat and Fadeyibi2019; Okojie et al., Reference Okojie, Wagbatsoma and Ighoroge2005; Isara et al., Reference Isara, Isah, Lofor and Ojide2010; Omemu & Aderoju, Reference Omemu and Aderoju2008), six studies in South Africa (Makhunga et al., Reference Makhunga, Macherera and Hlongwana2023; Marutha & Chelule, Reference Marutha and Chelule2020; Mbombo-Dweba et al., Reference Mbombo-Dweba, Mbajiorgu and Oguttu2022; Selepe & Mjoka, Reference Selepe and Mjoka2018; Nkhebenyane & Lues, Reference Nkhebenyane and Lues2020; Teffo & Tabit, Reference Teffo and Tabit2020), three studies in Tanzania (Jumanne & Sophia, Reference Jumanne and Sophia2014; Nonga et al., Reference Nonga, Simforian and Ndabikunze2014; Mariam et al., Reference Mariam, Mambosasa and Emmanuel2022), three studies in Ghana (Tuglo et al., Reference Tuglo, Agordoh, Tekpor, Pan, Agbanyo and Chu2021; Akabanda et al., Reference Akabanda, Hlortsi and Owusu-Kwarteng2017; Bigson et al., Reference Bigson, Essuman and Lotse2020), two studies in Malawi (Thandi & Campbell, Reference Thandi and Campbell2011; Matumba et al., Reference Matumba, Monjerezi, Kankwamba, Njoroge, Ndilowe, Kabuli, Kambewa and Njapau2016), one study in Kenya (Mwove et al., Reference Mwove, Imathiu, Orina and Karanja2020), one study in Sudan (Abdalla et al., Reference Abdalla, Suliman and Bakhiet2009), one study in Cameroon (Blaise, Reference Blaise2014), and one study in Rwanda (Ndoli & Nicholas, Reference Ndoli and Nicholas2019). The risk level of each study was assessed, and we found that all studies were rated as low risk of bias (Table 1).
Table 1. A descriptive summary of 42 studies in this systematic review and meta-analysis
Note: CB = Community-Based, CSS = Cross-Sectional Study, IB = Institutional-Based, PFHP = Prevalence of Food Hygiene Practices.
Quality assessment
After screening the relevant studies, the selected studies were appraised for methodological validity using Joanna Briggs Institute (JBI) appraisal tool for prevalence studies (Moola et al., Reference Moola, Munn, Tufanaru, Aromataris, Sears, Sfetcu, Currie, Qureshi, Mattis and Lisy2017). The tool had a total of eight questions (Q1–Q8), and those studies with positive answers of more than 50% of the tool (i.e. ‘Yes’ for 5 or more questions of the JBI tool) were included in this meta-analysis. The scoring was done by two authors (YAA and KAG), with the discrepancies resolved with discussion and consensus. When the disagreement between the two authors was not resolved with discussion, the third author (NAG) involved was a breaker. During the appraisal of each primary study, more emphasis was given to the appropriateness of the study objectives, study design, statistical analysis, any source of bias, and its management methods. Studies were considered low risk when they scored 50% and above on the quality assessment indicators, as reported in Table 2.
Table 2. Quality assessment of the included studies using the Joanna Briggs Institute (JBI) quality appraisal criteria
Note: Y = Yes, N = No, S = Scores, OQA = Overall Quality Assessment, LR = Low Risk.
Risk of bias assessment
The tool developed by Hoy et al. was used to assess the risk of bias for each included study (Hoy et al., Reference Hoy, Brooks, Woolf, Blyth, March, Bain, Baker, Smith and Buchbinder2012). The tool consists of 10 items that assess four areas of bias: internal validity and external validity. Items 1–4 evaluate selection bias, non-response bias, and external validity. Items 5–10 assess measure bias, analysis-related bias, and internal validity. The tool included (Q1) population representation, (Q2) sampling frame, (Q3) methods of participant selection, (Q4) non-response bias, (Q5) data collection directly from subjects, (Q6) acceptance of case definition, (Q7) reliability and validity of study instruments, (Q8) type of data collection, (Q9) length of prevalence period, and (Q10) adequacy of numerator and denominator. Studies were classified as ‘low risk’ if 8 and above of 10 questions received a ‘Yes’, ‘moderate risk’ if 6 to 7 of 10 questions received ‘Yes’ and ‘high risk’ if 5 or lower of 10 questions received a ‘Yes’. Therefore, all included studies had a low risk of bias (Table 3).
Table 3. Risk of bias assessment of the included studies
Note: Y = Yes, N = No.
Pooled prevalence of food hygiene practices in sub-Saharan Africa
A random effects model by DerSimonian and Laird was used to determine the overall pooled prevalence of food hygiene practices in sub-Saharan Africa. Accordingly, using a random effects model, the pooled prevalence of food hygiene practice among food handlers in sub-Saharan Africa was found to be 50.68% (95% CI: 45.35, 56.02) with a heterogeneity index (I 2) of 97.8% (p < 0.001) (Fig. 2).
Figure 2. Forest plot displaying the pooled prevalence of food hygiene practice in sub-Saharan Africa.
Sub-group analysis for practices
Due to the significant heterogeneity observed, various factors were used to conduct sub-group analysis in this meta-analysis, including country, study setting, sample size, and sampling methods. Consequently, sub-group analysis revealed that the country of Kenya had the highest prevalence of hygienic food handling practices at 78.30% (95% CI: (73.95, 82.65)), followed by Ghana at 71.09% (95% CI: (59.41, 82.77)) and South Africa with 68.04% (95% CI: (58.99, 77.10)). In contrast, the lowest prevalence was observed in Malawi, where the prevalence of hygienic food handling practices was 20.90% (95% CI: (−2.911, 44.71)).
A sub-group analysis was performed based on the study sites. The prevalence of food hygiene practices was 55.72% (95% CI: (46.83, 64.61)) for institutional studies and 46.89% (95% CI: (40.19, 53.58)) for community-based studies. In addition, a sub-group analysis was conducted on studies using different sampling methods, including probability, nonprobability, and both. The prevalence of food hygiene practices in these studies was found to be 48.80% (95% CI: (42.84, 54.77)), 56.63% (95% CI: (42.13, 71.13)), and 57.30 % (95% CI: (32.28, 82.32)), respectively (Table 4).
Table 4. Sub-group analysis for the pooled prevalence of food hygiene practices in sub-Saharan Africa (n = 42)
Sensitivity analysis
In addition to conducting sub-group analyses, we performed a sensitivity analysis by excluding each study to investigate the origin of heterogeneity. This analysis showed that omitting one study had no statistically significant effect on the overall evaluation of the studies (Table 5).
Table 5. Sensitivity analysis for the prevalence of food hygiene practices in sub-Saharan Africa
Meta-registration
In addition to conducting sub-group and sensitivity analyses, meta-regression was performed to detect sources of heterogeneity by country, sampling method, and study setting. The meta-regression results revealed no apparent source of heterogeneity by sample size, sampling technique, and year of publication (Table 6).
Table 6. Meta-regression analysis of factors affecting between-study heterogeneity
Publication bias
The distribution of food hygiene practice was examined for asymmetry through a visual inspection of the forest plot presented as a funnel plot. Furthermore, Egger’s and Begg’s regression test results demonstrated the non-existence of publication bias (p = 0.31) and (P = 0.93), respectively (Fig. 3).
Figure 3. Forest plot displaying the asymmetrical distribution of the included studies.
Factors associated with food hygiene practice in sub-Saharan Africa
We performed a meta-analysis to identify associated factors for food hygiene practices using the random effects model. During the extraction process, we planned to show the association of each factor with the outcome variable. A total of 42 studies were included in the analysis of the factors associated with food hygiene practices. Therefore, we examined the pooled effect of four factors on the outcome variable such as food safety training, regular medical examinations, and levels of attitudinal factors.
Among 42 articles analyzed, seven studies indicated a significant association between hygienic food handling practices and food safety training (Abegaz, Reference Abegaz2022; Werkneh et al., Reference Werkneh, Tewelde, Gebrehiwet, Islam and Belew2023; Tuglo et al., Reference Tuglo, Agordoh, Tekpor, Pan, Agbanyo and Chu2021; Azanaw et al., Reference Azanaw, Gebrehiwot and Dagne2019; Alemu et al., Reference Alemu, Motbianor, Birhanu and Birara2023; Alemayehu et al., Reference Alemayehu, Aderaw, Giza and Diress2021; Adane et al., Reference Adane, Teka, Gismu, Halefom and Ademe2018). Findings revealed that individuals who underwent food safety training were 2.14 times more inclined to employ hygienic food handling practices compared to those who did not receive training 2.14 (OR: 2.14, 95% CI: (0.68, 6.76)).
Six articles indicated a significant association between attitudes and food hygiene practices (Abegaz, Reference Abegaz2022; Werkneh et al., Reference Werkneh, Tewelde, Gebrehiwet, Islam and Belew2023; Tuglo et al., Reference Tuglo, Agordoh, Tekpor, Pan, Agbanyo and Chu2021; Alemu et al., Reference Alemu, Motbianor, Birhanu and Birara2023; Alemayehu et al., Reference Alemayehu, Aderaw, Giza and Diress2021; Yenealem et al., Reference Yenealem, Yallew and Abdulmajid2020). Findings revealed that individuals with a positive attitude were found to be 2.36 times more likely to adopt food hygiene practices than those with a negative attitude 2.36 (OR: 2.36, 95% CI: (1.36, 4.09)). These results highlight the importance of attitudes in promoting hygienic food handling practices.
In addition, four studies were analyzed to examine the association between handlers’ adherence to hygienic food handling practices and their regular medical examination, (Alemu et al., Reference Alemu, Motbianor, Birhanu and Birara2023; Teferi, Reference Teferi2022; Adane et al., Reference Adane, Teka, Gismu, Halefom and Ademe2018; Tamiru et al., Reference Tamiru, Bidira, Moges, Dugasa, Amsalu and Gezimu2022). Results revealed that individuals who did not receive routine medical checkups were discovered to have a 2.66 times higher likelihood of participating in unsanitary food handling behaviors compared to those who did undergo regular medical examination 2.66 (OR: 2.66, 95% CI: (1.52, 4.65)).
Moreover, in this study, seven articles were examined to determine the association between educational status and food hygiene practices. Findings revealed that educational status is not significantly associated with food hygiene practices at (P = 0.059). Six studies were used to estimate the association between knowledge and hygienic food handling practices among food handlers. Findings revealed that there is no significant relationship between knowledge and food hygiene hygienic practices at (P = 0.526). There was also a large heterogeneity (I2 = 96.0% and P = 0.001) among the included studies (Table 7).
Table 7. Factors associated with food handling practices among food handlers in sub-Saharan Africa
Discussion
Food safety standards are the basis for controlling disease transmission from the food processor to the consumer (Uyttendaele, Reference Uyttendaele, Franz and Schlüter2016). Food contamination and foodborne disease outbreaks are largely driven by food processors’ understanding and food hygiene practices, particularly in sub-Saharan Africa where food hygiene regulations are lax (Odeyemi, O. A. Reference Odeyemi2016). This systematic review aimed to determine the pooled prevalence of food hygiene practices and associated factors in sub-Saharan Africa.
In this study, the overall pooled prevalence of food hygiene practices among food handlers was found to be 50.68%. This result is almost consistent with earlier meta-analysis in Ethiopia (50.5%) (Zenbaba et al., Reference Zenbaba, Sahiledengle, Nugusu, Beressa, Desta, Atlaw and Chattu2022)). However, this finding is higher than studies conducted in Turkey (48.4%) (Mohlisi Mohd Asmawi et al., Reference Mohlisi Mohd Asmawi, Azureen Norehan, Salikin, Ain Syafiqah Rosdi, Amira Thaqifah Abdul Munir, Balqis Muhammad Basri, Ikhsan Selamat and Md Nor2018). The disparity could be attributed to differences in procedure or variations in social cultural and personal hygiene practices. It might be also linked to inequitable sanitary conditions among food handlers, such as a lack of safe water and other sanitary facilities, which can contribute to poor adherence to food hygiene practices. Nevertheless, this finding is lower than the findings from Indonesia, (90%), Saudi Arabia (80.29%), Jordan (89.43%), and earlier meta-analysis study done in Ghana (55.8%) (Sharif & Al-Malki, Reference Sharif and Al-Malki2010; Sharif et al., Reference Sharif, Obaidat and Al-Dalalah2013; Lestantyo et al., Reference Lestantyo, Husodo, Iravati and Shaluhiyah2017; Tuglo et al., Reference Tuglo, Mishra, Mohapatra, Kortei, Nsor-Atindana, Mulugeta and Doku2023). The potential reason for this discovery may be attributed to the presence or absence of training opportunities, and in developing countries, several establishments operate without employing properly trained staff to handle food, and without implementing a system for conducting regular health assessments.
The prevalence of food hygiene handling practices in sub-Saharan Africa varies across countries, as considered by the sub-group analysis conducted in this study. These variations can be attributed to several factors such as socioeconomic conditions, environmental influences, and behavioral characteristics of food processors, and inequalities within countries due to differences in premises of food establishments. The included studies demonstrated significant heterogeneity due to differences in the training of study populations as an intervention and timing of outcome measures.
In addition, this study aimed to identify the factors associated with food hygiene practices among food handlers in sub-Saharan Africa. Accordingly, food safety training, regular medical examination, and a positive attitude were significantly associated with hygienic food handling practices. Food handlers who haven’t received food hygiene training are more likely to perform unsafe food handling than those who have received the training. This conclusion is supported by research conducted in Bangladesh (Rahman et al., Reference Rahman, Arif, Bakar and Talib2016) and Malaysia (Mohlisi Mohd Asmawi et al., Reference Mohlisi Mohd Asmawi, Azureen Norehan, Salikin, Ain Syafiqah Rosdi, Amira Thaqifah Abdul Munir, Balqis Muhammad Basri, Ikhsan Selamat and Md Nor2018). Training can improve the overall performance of food handlers in safe food handling. Therefore, food safety training appears to be a reliable indicator of food hygiene practices.
In this study, food handlers who exhibited positive attitudes were more likely to have food hygiene practices than those with negative attitudes. These results are consistent with previous studies conducted among food handlers in Brazil (Da Cunha et al., Reference Da Cunha, Stedefeldt and De Rosso2014) and Malaysia (Abdul-Mutalib et al., Reference Abdul-Mutalib, Abdul-Rashid, Mustafa, Amin-Nordin, Hamat and Osman2012). People who are more worried about the causes of foodborne diseases, and the consequences for their health make them engage in more protective behaviors (Mohlisi Mohd Asmawi et al., Reference Mohlisi Mohd Asmawi, Azureen Norehan, Salikin, Ain Syafiqah Rosdi, Amira Thaqifah Abdul Munir, Balqis Muhammad Basri, Ikhsan Selamat and Md Nor2018). It is important to note that the attitude of food handlers plays a crucial role in translating food hygiene practices into observable measures, highlighting their influence on the level of handling practices.
Furthermore, regular medical examinations are associated with food hygiene practices, as evidenced by the fact that people who undergo medical examinations are more likely to demonstrate food handling practices compared to those who do not. This finding is consistent with previous research conducted in Bangkok, (Cuprasitrut et al., Reference Cuprasitrut, Srisorrachatr and Malai2011). Healthcare workers who advised food handlers during the examination, enhancing their food handling practice and food handlers who are health-checked, have a better understanding of how to handle food safely. Therefore, workers undergo a medical examination before starting to work with food.
On the other hand, the combined findings of this meta-analysis shows no significant association between educational status and food hygiene practices. However, one earlier meta-analysis in Ethiopia examined, a significant association (Zenbaba et al., Reference Zenbaba, Sahiledengle, Nugusu, Beressa, Desta, Atlaw and Chattu2022). Other studies concluded, in support of the current study (Mohlisi Mohd Asmawi et al., Reference Mohlisi Mohd Asmawi, Azureen Norehan, Salikin, Ain Syafiqah Rosdi, Amira Thaqifah Abdul Munir, Balqis Muhammad Basri, Ikhsan Selamat and Md Nor2018). Then, validating the concept of good hygienic food handling is primarily accomplished through effective food safety training for food handlers. Moreover, this finding showed that simply having knowledge about food hygiene does not necessarily translate into the implementation of safe food handling practices among individuals. In contrast, a meta-analysis performed in Ethiopia and Ghana found a significant association (Zenbaba et al., Reference Zenbaba, Sahiledengle, Nugusu, Beressa, Desta, Atlaw and Chattu2022; Tuglo et al., Reference Tuglo, Mishra, Mohapatra, Kortei, Nsor-Atindana, Mulugeta and Doku2023). Various factors may contribute to this disconnect, including personal attitudes, cultural beliefs, and access to resources that facilitate proper food hygiene.
Strengths and limitations of the study
This study was a first-of-its-kind systematic review and meta-analysis that estimated the pooled prevalence and associated factors of food hygiene practices in sub-Saharan Africa. To reduce the effects of selection bias, a systematic literature review was conducted focusing on clearly defined criteria. However, there are limitations to this study. We only searched papers published in English, and this study did not encompass qualitative research.
Conclusion
In this study, only half of the food handlers in sub-Saharan Africa had good food hygiene practices. Lack of food safety training, a lack of regular medical checkups, and unfavorable attitudes toward food hygiene practices were all factors contributing to food hygiene practices. Thus, the authors recommended that food workers should have regular medical checkups and receive food safety training about food hygiene and safety procedures.
Data availability statement
The dataset and all the relevant files are found by the primary author and can be gained from the authors upon convincing request.
Acknowledgements
We would like to express our gratitude to the investigators of primary studies and the database owners.
Author contributions
Y.A.A.: writing – original draft data, writing review and editing, data curation, methodology, conceptualization, formal analysis, and software. N.A.G.: formal analysis, validation, investigation, visualization, conceptualization, and data curation. K.A.G.: writing – review and editing, validation, investigation, visualization, formal analysis, and software. Finally, all authors reviewed and approved the final version of the manuscript.
Funding statement
The author(s) received no financial support for the research.
Competing interests
The author(s) declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.
Ethical standards
Not applicable.
Research registration number
Not applicable.
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