INTERNATIONAL SCHOOL OF ASIA AND THE PACIFIC

Bulanao Norte, Tabuk City, Kalinga

COLLEGE OF MEDICAL TECHNOLOGY

KNOWLEDGE, ATTITUDES, AND PRACTICES OF FOOD HANDLERS IN BULANAO, TABUK

CITY, KALINGA ON INTESTINAL PARASITIC INFECTION
A Qualitative Research

By:
Amangan, Airalyn B.
Balweg, Brigitte D.
Batac, Cleveland O.
Dulliyao, Precious C.
Maloc, Shechinah Ruth O.
Ramos, Cherubim L.

SUBMITTED TO:
JOEMAR STEAVE F. ABANILLA, RMT
Research Adviser

CHAPTER I
INTRODUCTION

Background of the study

Parasitic infections is one of the recognized neglected tropical
diseases (NTD) and is an important health problem. It is more common in
developing countries like the Philippines.
In the 2022 local data of the Rural Health Unit III of Bulanao,
Tabuk City, Kalinga on food handlers, one Giardia lamblia infection was
recorded, 11 E.coli, and 47 blastocyst.
The known leading causes of morbidity and mortality in the
underdeveloped world are diarrheal diseases which are caused by food
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borne or waterborne microbial pathogens, resulting in an estimated 1.9
million deaths annually at the global level.(Kuti, et al.,2020)
According to the World Health Organization(WHO), nearly two-thirds
of the world is infected with one kind of intestinal parasite and the
highest rate among all kinds are Ascaris and Giardia infections.
(Balarak, et al.,2016).
Moreover, 2013-2015 Nationwide Prevalence Survey of Soil-
Transmitted Helminths (STH) and Schistosomiasis Among School Age
Children In Public Schools In the Philippines conducted by Tangcalagan
D. et.al., (2022) of the 26,171 school children with stool samples
examined, 28.4 percent were infected with at least one soil-transmitted
helminth (STH). Infections among female students were significantly
lower than male students. The cumulative prevalence of soil-transmitted
helminthiasis among school-aged children was higher than the global
figure of 24.0%.
Prevalence of intestinal parasite infections in the community is a
threat to health. Moreover, the literature that we read requires further
study to match findings and the studies we have read lacked in
identifying parasite carriage of fingernail contents and also parasite
intensity was not mostly assessed.
Infections by intestinal parasites are linked to poor personal
hygiene and sanitation hence in this study focusing on intestinal
parasitic infection wherein Bulanao, Tabuk City was chosen as the area
of study where it may serve as a baseline information for the health and
sanitation needs of food handlers in Bulanao. Furthermore, it may drive
behavior change of the food handlers since during the conduct of the
study, the respondents may gain more awareness of intestinal parasitic
infections and food handlers were chosen as the respondents since they
are mostly the ones who prepare foods and managers of hygiene for the
consumers since food handling as well as hygiene is directly related to
intestinal parasitic infection.
The aim of this study therefore, is to determine the knowledge,
attitudes, and practices of food handlers in Bulanao, Tabuk, City on
intestinal parasitic infection which is supported with past related

2
studies which can be utilized by the municipal health office,
community, food handlers, researchers, and future researchers and help
them in identifying the health and sanitation needs of the population
study regarding prevention and control of intestinal parasitic
infections.

Conceptual framework
The Food Safety Act 2013 (Republic Act No.10611) is an act to
protect consumer health and facilitate market access of local foods and
food products, and for other purposes by strengthening the food safety
regulatory system in the country. To strengthen the food safety
regulatory system in the country, the state shall adopt the following
objectives:
 Protect the public from food-borne and water-borne illnesses and
unsanitary, unwholesome, misbranded, or adulterated foods
 Enhance industry and consumer confidence in the food regulatory
system and,
 Achieve economic growth and development by promoting fair trade
practices and sound regulatory foundation for domestic and
international trade.
In order to attain these objectives, implementation of the
following measures is necessary:
 Delineate and link the mandates and responsibilities of the
government agencies involved
 Provide a mechanism for coordination and accountability in the
implementation of regulatory functions
 Establish policies and programs for addressing food safety hazards
and developing appropriate standards and control measures
 Strengthen the scientific basis of the regulatory system, and

 Upgrade the capability of farmers, fisherfolk, industries,

consumers, and government personnel in ensuring food safety.
Moreover, food handling is an important pillar in achieving food
safety which contributes in the attainment of the health-related
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objectives of SDG 3. To elaborate, SDG 3 aims to ensure healthy lives
and promote well-being for all, at all ages. Based on the Sustainable
Development Goals (SDGs) by the United Nations International Children's
Emergency Fund, SDG 3 advocates the idea that health and well-being are
important at every stage of one's life, starting from the beginning.

Figure 1: knowledge - attitudes - practices model

Retrieved from
https://www.researchgate.net/publication/358195144_Beyond_Knowledge_Atti
tude_and_Practice_KAP_A_Study_on_the_COVID-
19_Pandemic_Situation_In_Bangladesh
The study utilizes the Knowledge Attitudes and Practices(KAP) model
shown in figure 1 where attitude is affected by knowledge and practice
is affected by knowledge and attitude. Food safety is attainable when
food handlers and other food managers such as farmers and factories are
knowledgeable on safety food management.

Statement of the problem

Generally, this aims to assess the level of knowledge, attitudes,
and practices of food handlers in Bulanao, Tabuk City, Kalinga on
intestinal parasitic infection.
Specifically, this aims to answer the following questions:
1.What is the profile of respondents:
A.Demographic
a.1.Age
a.2.Marital Status
a.3. Available Learning Sources at home on intestinal parasitic
infection.
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B.Socio-economic
b.1. Educational Attainment
b.2. Ethnic Affiliation

C.Health-Seeking Behavior
c.1. Health Professional/s sought for medical consultation.
c.2. Frequency of consultation

2.What is the knowledge of respondents on intestinal parasitic

infection?
A.Pathophysiology
B.Signs and Symptoms
C.Treatment and Management
D.Prevention and Control
3.What are the attitudes of respondents on intestinal parasitic
infection?
4.What are the practices of respondents on intestinal parasitic
infection?
5.Is there a significant difference between the knowledge, attitudes,
and practices of respondents when grouped to profile variables?
6.Is there an association between the knowledge of the respondents to
their attitudes and practices on intestinal parasitic infection?

Paradigm of the Study

Independent variables Dependent Variables
 Food handlers  Attitude of food handlers

 Demographic profile towards intestinal

parasitic infection
 Socio-economic profile
 Practices of food handlers
 Health profile
on the prevention,
 Health seeking behavior control, and management of
 Knowledge of mothers intestinal parasitic
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  Prevalence of disease
because of polluted
environment.
 Deworming practices
infections.
 Implications of intestinal
parasite infections
 Intestinal parasitic
infection rate of food
handlers

Definition of terms
Food handler- anyone who handles package or unpackaged food directly as
well as the equipment and utensils used to prepare or serve food and or
surfaces that come into contact with foods
Knowledge- understanding and awareness of the various aspects of this
group of diseases caused by parasitic worms.
Attitudes- refer to the perspectives or feelings that individuals or
communities hold towards intestinal parasitic infection.
Practices- refer to the actual behaviors or actions that individuals or
communities undertake in relation to the prevention, management,
treatment of the diseases.
Intestinal parasites- parasitic worms that can infect children and cause
various health conditions.
Intestinal parasitic infection- a group of diseases caused by infection
with parasitic worms which can lead to a variety of symptoms, depending
on the type and location of the infection.
Deworming- refers to the process of administering medication to
individuals or communities to treat and prevent intestinal parasitic
infections.
Parasites- it can cause a range of health problems in their host,
depending on the specific species and the location of infection.
Asymptomatic- refer to the unobservable indication and subjective
experience that individuals may not present with when infected with
intestinal parasitic infection.

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Treatment- refers to the interventions and strategies aimed at
eliminating or reducing the burden of intestinal parasitic infections in
affected individuals.
Prevention- refers to the strategies and measures aimed at reducing the
incidence and transmission of intestinal parasitic infection.
Food- refers to a physiological need which sometimes can possibly be a
source of infection.
Food borne diseases- pertain to the type of infections that are acquired
via ingestion of contaminated food.
Food preparation- connotes the complete process of preparing food which
will be evaluated in this particular study.
Hygiene- refers to the condition or act of maintaining good health and
avoiding diseases by means of cleanliness.
Infection- connotes the state of acquiring a specific pathogen that
needs to be treated accordingly.
Sanitation- refers to the condition related to public health safety.
This particular condition will be identified and evaluated in this
study.

Significance of the study

This study is conducted with the aim to provide knowledge and ideas
which is supported with past related studies and significant sites to
which will become beneficial to the following:
Municipal Health Office, this study could be used to inform health
authorities about the need for educational campaigns and treat these
intestinal parasitic infections, especially in populous areas like
Bulanao, Tabuk City,Kalinga.
Food establishments owner’s,the result of the study help to
identify and address the problems using this information in our research
to look for strategies on how to minimize this infection.

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 Food handlers, this study will disseminate information and will use
as their guidelines in preventing and controlling intestinal parasitic
infection.
Students, the result of the study could be instructive in choosing
which topic they will pursue to study when it’s their time to do
research and with this they will be motivated to study more about this
topic.
Researcher, this study provides informative knowledge for them in
doing their study. Furthermore, this serves as a reference for them who
are doing a study similar to this topic.
Future Researchers, the result of this study will serve as a
foundation in working their own research. In addition, they will get
ideas related to the topic.

Scope and delimitation

This study was conducted to enhance the knowledge, attitudes, and
practices of food handlers residing in Bulanao, Tabuk City, Kalinga
about parasitic intestinal infection as well as to further improve the
awareness and proper action of food handlers need in order to avoid
parasitic intestinal infection. Moreover, the study may keep records of
intestinal worm infections during conduct.
Among different demographic profiles that may describe the
respondents, the present study only included age, marital status,
available Learning Sources at Home on parasitic intestinal infection.
The respondents of the study included all food handlers of Bulanao,
Tabuk City, Kalinga.
The researchers will utilize a structured questionnaire from the
internet. The questionnaires will be translated into Filipino and back-
translated prior to being distributed to the respondents for the conduct
of the research study. The questionnaire will gather their demographic,
socio-economic, and health-seeking profile and assess the knowledge,
attitudes, and practices of the respondent food handlers on parasitic
intestinal infection.
The duration of the study is from September 2023 to July 2024.
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 CHAPTER II
Review of Related Literature
I. Knowledge of Food Handlers on Intestinal Parasitic Infection
According to a study conducted by Gary Antonio C. Lirio et. al,.
(2017) in their different target areas in Metro Manila, infections by
intestinal parasites are considered as one of the major health problems
in developing countries afflicting different groups of people including
food handlers and food vendors and are linked to poor personal hygiene
and sanitation. This raises public health issues because food handlers
and vendors may potentially become agents for the fecal-oral
transmission of intestinal parasitic infections to consumers.
There are chronic and insidious effects of parasitic infections
including anemia, growth retardation, impairment of cognitive and
physical development and mortality. This can be acquired thru intake of
contaminated water and food containing infective stages of the
parasites. The common ways linked to infections are direct contact with
contaminated water, feces, soil and vegetation.
Among the groups at risk for parasitic infections are food handlers
who serve in institutions like schools, hotels,jails including sidewalk
or street vendors. Unsanitary environment where food preparation is done
is particularly one of the several factors known to favor food-borne
parasitic transmission. In addition to that, limited access to clean
water, overcrowding, poor personal hygiene of food handlers and servers,
improper cooking of meat, poor storage of food and drinks are other
factors. Additionally, contaminated meat may also enter the consumer
market that can build up parasitism.
The results showed that there is a higher rate of parasitic
infections among males than females regardless of the type of parasite/s

9
detected. Natural hygiene-conscious behavior of females is one possible
reason for the lower prevalence among them.
In relation to age, the prevalence of intestinal parasitic
infections compared to the overall positive samples was higher among
individuals within the age of 41-50 years old followed by the
participants within the age group of 21-30 years old. The five
participants who are 50 years old and above are observed to be all
infected. This can be linked to the suppressed immune system of older
individuals.
Several studies linked the likelihood of STH infection as
significantly higher among poor individuals. This is supported by the
current findings with higher prevalence of parasitic infections among
participants with a monthly income of P10,000.00 and below and most
prevalent among participants with a monthly income of P5,000.00 and
below.
It is also notable that all participants with elementary, either
graduate or undergraduate, as the highest educational attainment are
infected by intestinal parasites. The participants who had the lowest
prevalence were those who graduated in college.
Among the 91 participants, 82 are infected with any intestinal
parasites. Infection with only one helminth species was the most common
while infection with dual helminths infection per infected participant
was rare. Multiple parasitic infections were also detected among 28
participants. Protozoan was also detected from some participants. Nine
species of parasites were detected from the participants including
Ascaris lumbricoides which was the most common detected parasite and the
least detected parasites are Giardia lamblia, Enterobius vermicularis,
Ancylostoma duodenale/Necator americanus and Taenia spp. The other
common parasites detected were Amoeba which includes Entamoeba
histolytica, Trichuris trichiura, and Balantidium coli.
Moreover, intestinal parasitic infection is usually linked to
zoonosis, however, the quality of food taken by the food vendors and
slaughterhouse workers can give light to possible route of parasite
transmission. The participants are likely to patronize affordable food

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for the consumers which happens to be usually cheap but unsafe since
most of them have a low economic status.
In another study conducted by Yonas Yimam, et al,.(2020) food
handlers, people involved in preparing and serving food, working with
poor personal hygiene could pose a potential threat of spreading
intestinal parasites to the public in a community.
The overall pooled prevalence estimate of intestinal parasites
among food handlers of food service establishments in Ethiopia was 33.6
percent. The most predominant intestinal parasites from food handlers
were Entamoeba histolytica/dispar and Ascaris lumbricoides among ten
intestinal parasites identified.
In another study conducted by Davoud Balarak, et al.(2016) in
Northwest Iran, parasitic diseases pose health problems in many
countries, most especially in developing countries. In the absence of
sanitation, workers at food centers could transmit parasitic infections.
Parasitic infection was observed in 172 cases of 4612 samples. A total
of 156 positive samples were related to protozoa and 16 were related to
helminthes. The lowest infection was related to H.nana and most of the
parasitic infections were related to Giardia and Entamoeba coli.
The results show that the prevalence of intestinal parasites,
especially pathogenic protozoa, is common in some food handlers. These
studies have been conducted in the past decade and show high amounts of
parasitic infection, but significant decline parallel to improvement of
public health. Strict enforcement of sanitary regulations in recent
years is one of the most effective methods in reducing parasitic
infection, so that all people in Tabriz were issued a Health Care Card
and parasitological tests were performed on them accurately.
The highest prevalence of infection was in supermarket and sandwich
and pizza businesses. Also the prevalence level was reported to be 30.2
percent in another survey that was conducted by Rouhanie et al. in
Nowshahr and Chaloos on various food vendors. Intestinal parasitic
infection in food handlers of Gorgan also was equal to 6 percent as
reported by Koohsar et al. According to these observations, most

11
parasitic infections were caused by butchery staffs by 25 percent.
Giardia was the cause of the highest rate of infection.
In another similar study conducted by Kamau et al. in Kenya,
Giardia parasite was found out to be one of 6 common types of parasites
among restaurant members.
Although supermarket workers as other businesses have no direct
contact with food, contamination is possible when foods are uncovered.
Therefore, sandwich, pizza, and restaurant handlers have the most
contribution in incidence of parasitic infection after supermarkets
since they have direct contact with food thus, the staff in these sites
require personal and professional hygiene in their work environment, and
these health professionals are decisively required to follow up and
monitor.
The studies conducted in Saudi Arabia and Sudan cleared that
Giardia and E.histolytica parasites were observed in food handlers and
the infection rate of Giardia parasite was very high in Sudan.
The results show that the prevalence rate of intestinal parasites,
particularly Giardia protozoan, in food handlers is 3.73 percent. This
percentage of infection between the workers in food producing places can
be considered as an important way to transmit these infectious agents
among the public.
Furthermore, conducting training and educational programs may
increase the knowledge of the workers towards these infections and the
associated risk to themselves and their community.
In another study conducted by Roel Nickelson M. Solano, RMT et al.
(2023) food consumption is indeed vital, and food safety must always be
observed. However, unsafe food consumption is the cause of 600 million
cases of food borne diseases such as parasitic infections.
Moving forward, knowledge is an essential factor in alleviating
food-borne disease transmission. Having the educational background
important to food safety will help address food-borne diseases.
In another study conducted by Rujina-Dios Z. Alfelor et al.(2021)
with the concern of determining the impact of knowledge on pathogenic
meat-borne parasites on the current food safety and food handling

12
practices of selected tertiary students in a selected university in
Manila.
The respondents’ knowledge about pathogenic meat-borne parasites
was graded using the modified Bloom’s cut-off point. It is seen that
most of them have moderate scores from 29 to 45 points. Furthermore, 126
respondents have a good mark of greater than or equal to 46 points while
only some attained poor scores of less than or equal to 28 points. It
can be interpreted that the majority of the respondents are considered
to have adequate knowledge, while the remaining either have a high level
of knowledge or low level of knowledge.
Majority of the respondents gained information from the internet
while some learned about meat borne parasites in school, some have taken
up courses such as Biology and Microbiology.
Therefore, it can be concluded that school and its curricula have
an impact on students’ knowledge on parasites and the diseases they
cause and that incorporating this information into their courses would
facilitate the development of safe habitual food handling practices.
Moreover, in a cross-sectional study conducted by Moges Lewetegn et
al.(2019) in Senbente and Bete Towns, North Shoa, Ethiopia, it showed
that the predominant parasite infecting preschool children are
Hymenolepis nana (23.8%), followed by Giardia lamblia (19.6%).
In another study conducted by Mesfin Wudu Kassaw et al.,(2019)
anti-heminthic treatment, improved water supply, and sanitation, and
health education are the basis of helminthiasis prevention. However,
lack of clean water, poor sanitation, and low coverage of education in
developing countries make the control measures difficult to implement.
Additionally, intestinal parasitic infestations have serious
consequences on human health such as hepatomegaly, splenomegaly,
esophageal varices, and delay in physical development. In addition to
that, a weak immune system, decreased level of intelligence, and
decreased labor productivity are other adverse effects of parasitic
infestations.
Moreover, the helminths are worm-like parasites. The separation of
clinically relevant groups are according to their general external shape

13
and the host organ they inhabit. There are both hermaphroditic and
bisexual species. The external and internal morphology of egg, larval,
and adult stages are the basis of definitive classification.
Adult and larval roundworms (nematodes) are cylindrical, bisexual
worms. Roundworms are nematodes (nemato from the Greek root meaning
“thread”).
Accessory sex organs that are external modifications of the cuticle
are possessed by male nematodes of several species.
Internally, an experienced observer can identify the alimentary,
excretory, and reproductive systems. Tapeworms are unique in lacking
alimentary canal and thus nutrients are absorbed through the tegument.
The blood flukes and nematodes are bisexual. All other flukes and
tapeworm species that infect humans are hermaphroditic. Adult flukes,
cestodes, and nematodes produced eggs that are passed in excretions or
secretions of the host.
Moving forward on parasitic infections, a study is conducted by
Arun Ghosh et al.(2014) on infestations amongst the food handlers in a
City of North Eastern Region of India where 300 food-handlers were
included in the study. Young adults and middle aged from 20 to 49 years
were the majority of the food-handlers. 88 stool specimens were positive
showing 99 different diagnostic stages of parasites. Some specimens were
infected by more than one parasite. The most frequent among the most
detected intestinal parasites is Ascaris lumbricoides followed by
Entamoeba histolytica. Trichuris trichiura, Giardia lamblia, and Taenia
species were the other parasites that were also detected.Most of the
food-handlers have poor hygiene practice and are residing in rural area
and slums.Prevention of food-borne infections among the public may
require routine screening of food handlers.
Food handlers being a major source, thus effective prevention and
control require the identification of local risk factors. The prevalence
of intestinal parasitic infections and associated risk factors among
food handlers of district Swat, Khyber Pakhtunkhwa, Pakistan from
January 2011 to December 2013 was assessed through the conduct of
presently occupation based cross sectional study. A total of 267 food-

14
handlers were enrolled, socio-demographic data and possible factors for
the occurence of intestinal parasitic infection were collected. Multiple
infections were identified in individuals. (Wali Khan et al.,2017)
In another study conducted by Mohammad Hossein Motazedian et al.
(2015) on prevalence of intestinal parasites among food-handlers in
Shiraz, Iran, it showed that intestinal parasitic infections are still
among socioeconomic problems in the world, especially in developing
countries like Iran. One of the most important sources to transmit
parasitic infections to humans are food-handlers that directly deal with
production and distribution of foods between societies.
The prevalence of parasitic organisms was 10.4% in the food-
handlers. G.lamblia, E.coli, and B.hominis were the most detected
species of the protozoan parasites. Meanwhile, only one infection by
H.nana was detected in this group. Of positive cases, mixed infections
were observed in 13.2%. There was no significant statistical difference
in the rate of infection among different educational and occupation
groups.
II. Attitude of Food Handlers on Intestinal Parasitic Infection
According to a study conducted by Roel Nickelson Solano, RMT et al.
(2023) food handlers are indeed a potential source of food-borne
infections. Thus in the food industry, even in the hospital, where food
is considered vital in the treatment process, hygienic and sanitary
control must be observed.
A high prevalence of parasitic intestinal infection in a tertiary
care hospital in Makkah, Saudi Arabia was found among the food
handlers, in the year 2009. Knowing hand hygiene practices is one way of
identifying the risk of transmitting food-borne infections from a
carrier food handler. Most microorganisms are acquired in the area
beneath fingernails, which are also the most difficult to sanitize.
Food preparation is indeed vital in ensuring the safety of the
foods that we eat. In a study conducted in 2019, 116 out of 288
vegetables were tested positive with food-borne parasites like Ascaris
lumbricoides. Having parasitically contaminated vegetables which source
might probably be from contaminated soil or water, food handlers

15
especially those who cater to the number of people to feed, must also
have regular checkups and sanitary training to avoid further
transmission. Nevertheless, the absence of intestinal parasites is not
justified by having a valid medical certificate because some medically
certified food handlers with valid medical certificates were tested
positive with different parasites particularly E.histolytica, G.lamblia
and A.lumbricoides in the study conducted by Kamau et al. in 2012.
In another study conducted by Rujina-Dios J. Alfelor et al.(2021)
on the impact of knowledge on pathogenic meat-borne parasites to food
safety practices of tertiary level students in a university in Manila,
Philippines, it is revealed in its findings that most of the students
who participated had some familiarity with meat-borne parasites and the
dangers of parasitic infections with the majority of them having an
adequate overall level of knowledge. Such findings are favorable because
risk of infection may be reduced due to adequate knowledge on the
subject matter which eventually lead to positive effect on preventing
parasitic infections as it translates to behavioral changes.
In another study conducted by Kemal Ahmed Kuti et al.(2020) among
food handlers working in Madda Walabu University, Ethiopia, intestinal
parasitic infection was one of the major health problems globally. It is
more common in developing countries like Ethiopia.
High prevalence of intestinal parasites was observed among symptom-
free food handlers who could be an unobservable source of disease
transmission. The independent predictors of intestinal parasitic
infection in the study are inadequate handwashing, untrimmed fingernail,
inadequate knowledge, and lack of training.
Unless the strict hygienic procedure is followed, food is highly
susceptible to contamination. Its contamination can occur at any point
during its journey starting from production through processing,
distribution, and meal preparation. About 2 million deaths occur
annually due to foodborne diseases in developing countries. Even in
developed countries, an estimated one-third of the populations suffer
from microbiological foodborne diseases annually.

16
 The major determinants of food contamination are the health status
and hygienic practices of food handlers. Most of the time, intestinal
parasitic infections are too difficult to control and eradicate since
they have a number of potential carriers, such as food handlers. Nearly
more than half of the cases of diarrheal disease in developing countries
are linked with the consumption of foods contaminated with intestinal
parasites.
A total of 198 food handlers who were eligible for this study gave
responses. About half of the participants were in the age range of 18-24
years while the majority of them were females. Accordingly 179 had
adequate handwashing practice and 38 of them were trained on food
handling and had certificates of training, respectively. Accordingly 41
covered their hair and wore a gown even though only 29 of the gowns were
clean and 104 of the participants had trimmed their fingernails.
Regarding types of foodborne diseases, the respondents mentioned
ascariasis, typhoid fever, amebiasis, giardiasis, and acute watery
diarrhea. With regard to things that play a role in foodborne diseases,
the respondents mentioned contaminated fluids, contaminated fingers,
flies, lack of hygiene, and feces.
Different methods of foodborne diseases prevention were mentioned
by the participants such as personal hygiene, optimal cooking of food,
and having regular medical checkup. Accordingly 75 of the participants
had adequate knowledge while 123 had inadequate knowledge about
foodborne diseases.
Out of the total of 198 stool samples investigated, 50 samples
tested positive for intestinal parasites. Ascaris lumbricoides,
Entamoeba histolytica/dispar, hookworm, Giardia lamblia, and
Strongyloides stercoralis were identified.
Inadequate hand washing practice, inadequate knowledge about
foodborne diseases, lack of training on food handling, and untrimmed
fingernail showed statistically significant association with the
presence or absence of intestinal parasite. Infection with intestinal
parasites could be due to improper food handling by carrier persons
working in food and drinking establishments. High prevalence of

17
intestinal parasites was observed among symptom-free food handlers who
could be an unobservable source of disease transmission.
The results of the study implied that policy makers, healthcare
officials, higher education administrators, and individuals directly or
indirectly involved in food handling should do their responsibility in
strengthening the training and regular medical checkup system for food
handlers.
In another study conducted by Paul Kamau et al.(2012) in certified
food-handlers working in food establishments in the City of Nairobi,
Kenya, the number of food eating places in towns and their environments
is rapidly increased by rural-to-urban migration. Some of the eating
establishments have poor sanitation and are overcrowded, facilitating
disease transmission especially by food-handling.
In a cross-sectional study conducted from February to May 2010 in
four orphanage centers using standardized and structured questionnaires.
A total of 80 stool samples from all food handlers were collected and
examined by Direct Fecal Smear(DFS) technique for intestinal parasites.
(Sintayehu Bedaso et al.2018)
The findings of the study showed that 14 of the food handlers from
all four orphanage centers were infected with one of either protozoan or
helminth parasites. A. lumbricoides was the most common intestinal
parasitic infection encountered among these infected individuals
followed by E. histolytica, G. lamblia, and Taenia species. The major
defects observed were improper food storage, poor personal hygiene, and
food handling practices of the food handlers and poor sanitary
facilities. (Sintayehu Bedaso et al.,2018)
One of the factors hugely contributing to food contamination are
the walls and ceilings of the kitchens in poor sanitary conditions. In
general, there is a high possibility of parasitic infection to children
with poor hygienic facilities of the centers and high prevalence of
intestinal parasites. (Sintayehu Bedaso et al.,2018)
In another study conducted by Vachel Gay V. Paller et al.(2022) on
environmental contamination with parasites in selected rural farms in
the Philippines: impacts of farming practices on leafy greens food

18
safety, a total of 168 vegetable, 55 soil and 15 water samples collected
from four selected farms and a reference farm were processed through
various standard parasitological techniques. Parasites’ eggs or cysts
were found on 17.3% of vegetables, 47.3% soil and 73.3% water samples.
More contamination was found on leafy vegetables, such as lettuce.
Results showed that the highest prevalence on farm soil and vegetables
is strongyloides/hookworms.
In all water samples in the farms there are other helminth parasite
eggs that were also recovered like Toxocara species, Ascaris species,
Trichiuris, Trichostrongylus species, and protozoan cysts of Balantidium
coli, Cryptosporidium species, oocysts, and Giardia species cysts.
Furthermore, results revealed that the factors that contribute to
parasite contamination in the farms were some farming practices such as
the use of improperly treated animal manure as fertilizers, unhygienic
practice of farmers and sanitation issues. Control and prevention of
parasite contamination at the farm level is recommended in the study.
Food-borne disease because of intestinal parasites (IPs) and
enteric bacterial infections (EBIs) remain a major health problem. A
potential threat of spreading IPs and EBIs to the public could be posed
by food handlers, individuals preparing and serving food, working with
poor personal hygiene. A total of 5844 food handlers were included. The
overall pooled prevalence of IPs and EBIs among food handlers in four
selected regions of Ethiopia was 29.16%. The most prevalent IPs among
food handlers were Ascaris lumbricoides, Entamoeba histolytica/dispar,
Giardia lamblia, and hookworm. The most prevalent EBIs were Salmonella
and Shigella species. Low prevalence of IPs and EBIs was observed in
Tigray region. On the other hand, a high prevalence was observed in
Oromia. The factors significantly associated with the prevalence of IPs
and EBIs were food handlers who had not taken food hygiene training,
untrimmed finger nail, lack of periodic medical checkup, lack of
handwashing habits, and eating raw vegetables and meat. Therefore,
provision of proper health education and training regarding personal
hygiene, hand washing, food handling, medical checks, as well as raw
vegetable and meat safety is recommended in the study. (Abayeneh Girma,
2022)
19
 In another study conducted by Suvarna Sande et al.(2014) on
screening of food handlers for intestinal parasites and enteropathogenic
bacteria in a tertiary care hospital, food handlers with a personal
hygiene could be potential sources of infections of many intestinal
parasites and enteropathogenic bacteria. Those who are more susceptible
to infection like hospitalized patients especially those who suffered
from immunodeficient conditions may be more vulnerable from infections
in food handlers.
Cultures from swabs were positive for Staphylococcus aureus,
Enterococcus fecalis, Klebsiella pneumoniae, Escherichia coli,
Enterobacter species, and Citrobacter species apart from commensals.
Different intestinal parasites were found on thirty four stool
specimens.
In order to avoid diseases that can be acquired through improper
food handling like intestinal parasitic and bacterial infections,
screening of food handlers, training for food handling and hand hygiene
practices and regular monitoring of the food handling practices should
be done.
Food-handlers play an important role in the dissemination and
transmission of enteropathogenic microorganisms, including intestinal
parasites. Among food-handlers of Bandar Abbas, Southern Iran 34.9% of
participants were positive for stool parasites. Workers of bakeries,
factories, fast foods, supermarkets, restaurants, offices, butchers, and
coffee shops were observed to be the most infected individuals. (Mehrgan
Heydari-Hengami et al.,2018)
Blastocystis hominis, Entamoeba coli, Giardia lamblia, and
Dientamoeba fragilis were the intestinal parasites detected. One
infection by Enterobius vermicularis and only two infections by
Hymenolepsis nana were detected in the study. Direct contact with the
raw foodstuff and living in the workplace affected the prevalence of
intestinal parasites. (Mehrgan Heydari-Hengami et al.,2018)
In another study conducted by Elham Hajialilo (2019) on prevalence
of parasitic intestinal infections in food handlers in Qazvin, Iran, it
emphasized that food handlers play an important role in the production

20
and distribution of parasitic contaminations in these societies.
Totally, 1530 samples were collected from food handlers in Qazvin, Iran.
Blastocystis hominis, Giardia lamblia, Entamoeba coli, and Endolimax
nana are the protozoan species detected.
The most and least protozoan infections observed among the
specimens is Endolimax nana. The prevalence of intestinal parasites
among the food handlers based on variables including sex, age, job, and
education did not differ, whereas the prevalence of intestinal symptoms
was shown to be higher in infected food handlers.
Moreover, a high prevalence of enteric protozoan parasite infection
was also observed among the citizens of Roudehen, Tehran province,Iran.
The most common intestinal protozoan was Blastocystis species. To
elaborate, Entamoeba coli, Blastocystis species, Giardia intestinalis,
Dientamoeba fragilis, Iodamoeba butschlii, Entamoeba complex cysts or
trophozoite, Chilomastix mesnilii, and Enterobius vermicularis were
detected. A significant association of parasites with water source and
close animal contact were shown by multivariate analysis. Protozoan
infections were more common than helminth infections. Public and
individual education on personal hygiene should be considered to reduce
transmission of intestinal parasites in the population as most of the
species detected are transmitted through a water-resistant cyst.
(Hemmati, 2017)
In another study conducted by Yagoob Garedaghi & Yaghuob
Firouzivand (2014) on protozoan infections of restaurant workers in
Tabriz, Iran, it stated that sanitary measurement of the mentioned
places are not effective since double infection was observed with
Giardia and E.histolytica and the positivity in the majority of them was
single infection. Abdominal troubles, diarrhea, constipation, nausea,
and vomiting accompanied the infection caused by these parasites.
Despite increasing the level of public health, parasitic infection
is still one of the most important public health problems in the
community. Out of 87 studies cases in a study conducted to determine the
prevalence of intestinal parasitic infections in personnel employed at
the restaurants in Tabriz city, a total number of people with parasitic

21
infections were estimated to be 16. The most contamination in the
protozoa was related to Endolimax nana, Hymenolepsis nana. Ascaris
lumbricoides eggs were also detected. The distribution of contaminants
in women was significantly lower than men.

III. Practices of Food Handlers on Intestinal Parasitic Infection

In a study on intestinal parasites among food handlers conducted by
Gary Antonio C. Lirio, et al,.(2017) in their target areas in Metro
Manila among 91 participants, there were 65 out of 82 infected
participants who eat unwashed fruits and vegetables. Eating raw meat was
not a common practice among most of the participants but there were 16
out of the 91 participants practice eating raw meat wherein 14 of them
are infected with parasites.
While early reports show a high percentage of participants washing
their hands before meals, there is also a high percentage of
participants eating with bare hands. Using a spoon and fork is not
usually practiced among 65 from 82 infected participants.
To cover the risks of waterborne parasitism, participants were
asked regarding the water and the beverages they drink. Some of the
participants drink directly from the faucet without any treatment and 63
of them drink street-sold beverages like “buko” and “sago’t gulaman”
which may be possibly mixed with tap water.
Lastly, participants reported eating several types of street foods.
74 participants out of 80 who eat street foods were infected with
parasites.
On hygiene and sanitation, participants reported cutting of nails.
Long nails harbor most of the most microorganisms and are most difficult
to clean thus fingernails play an important role in any fecal-oral
human-to-human parasite transmission.
To further investigate the level of hygiene and sanitation, the
participants were asked about owning a toilet facility. Out of 91
participants, only 74 of them own a family or private toilet but there
are 66 participants who own a private toilet that still acquired
parasitic infection. Moving further, hand-washing after toilet use is

22
also a good indicator. Majority of the participants understood the
importance of hand-washing after defecation however, 2 participants,
either infected or not, answered no to this particular question.
This study strongly supports existing findings on how lack of
sanitary toilet facility may put the public at high risks of parasitic
infections.
The results of this study demonstrate high prevalence of intestinal
parasitic infection among food vendors and slaughterhouse workers in
Metro Manila.
In another study conducted by Yonas Yimam, et al,.(2020) food
handlers who washed hands after toilet use had 54 percent protection
from intestinal parasites compared to those who did not.Since food
handlers infected with intestinal parasites show sub-clinical signs and
are asymptomatic carriers, they are unaware of their potential role in
the spread of infections, and subsequently, it hinders control and
elimination. The impact of food handlers on spread of intestinal
parasites is high since they can directly or indirectly transmit
infections via food,water, nails, and fingers to a large number of food
and drink consumers of food service establishments like restaurants,
hotels, factories, canteens, schools, hospitals, prisons, or other
places where food is prepared and served to many people.
Factors like availability of clean water, the survival of the
environmental stages of the parasites, personal and public hygiene
practices play a central role in the transmission of intestinal
parasites apart from socio-economic factors.
Studies in Ethiopia indicated that the prevalence of intestinal
parasite infections among food handlers of food service establishments
are related to personal hygienic factors like hand washing after toilet
use, medical check-up including stool examinations, and knowledge about
intestinal parasites.
The overall pooled prevalence of being infected with at least one
intestinal parasite among food handlers of food service establishments
in Ethiopia was found to be 33.6 percent. Intestinal parasites noticed
from food handlers were Entamoeba histolytica/dispar, Ascaris

23
lumbricoides, Giardia lamblia, Hookworms, Strongyloides stercolaris,
Hymenolepsis nana, Taenia species, Enterobius vermicularis, Schistosoma
mansoni, and Trichuris trichiura. The most dominant intestinal parasite
among food handlers was Entamoeba histolytica/dispar while the least
prevalent was Schistosoma mansoni. Widespread open field defecation ,
the resistance nature of cyst to chlorination, the survival of cyst for
several weeks in the environment and the cyst no need of development and
maturation in the environment may be attributed to the highest
prevalence of Entamoeba histolytica/dispar in the current study. Also
most infected individuals are asymptomatic carriers and they continue to
shed eggs for a prolonged time.
Few of the major factors which determine the level of food
contamination is the hygiene practice and oral health status of food
handlers. A.lumbricoides was the predominant intestinal parasite
observed in the present study. Frequency of occurrence of intestinal
parasites among food handlers is very high. (Nanaware Balkrishna
Dattatray, 2016)

Food handlers who had food preparation training and medical check-
up had 29 and 30 percent protective effect than their counterparts. Also
food handlers who washed their hands before food preparation had 41
percent protective effect from gastrointestinal parasites compared to
food handlers who had not washed their hands before preparing food.
These relatively low protective effects of hygiene practices from
intestinal parasitic infections may be attributed to the presence of
confounding factors like poor socioeconomic status, low level of
sanitary conditions, safe water supply, latrine utilization and
inconsistent adherence to hygienic practice. Thus, regular screening,
training and personal hygiene practices of food handlers for intestinal
parasites should be imposed and monitored by employers, managers, or
owners of food and drink establishments.
Rapid urbanizations and increased prevalence of various food
practices are some of the factors of the drastic increase in the
prevalence of various food borne diseases. One consistent major concern

24
for developing countries is the quality assessment of the food sold at
various commercial centres. Since most of the infectious pathogens
transmit through food and water contamination, food handlers are a
potential source of transmitting infections. The prevalence of
intestinal parasites identified from food handlers included
A.lumbricoides which have the highest infection rate. G.intestinalis was
also observed as second highest in infection rate. E. histolytica and
Hookworm secies were least in infection rate. (Nanaware Balkrishna
Dattatray, 2016)
The oro-faecal route comprises the most common route of such
parasites. Some of the most common parasites affecting the people all
over the world are Giardia lamblia, Entamoeba histolytica, and Ascaris
lumbricoides.(Nanaware Balkrishna Dattatray,2016)
A.lumbricoides was the predominant intestinal parasite observed in
the present study. Zain MM et al. evaluated the socio-economic
characteristics, knowledge, attitudes, and practice towards food-borne
diseases and food safety among food handlers and revealed that none of
them had any license and a significant number of food handlers had no
certificate in food handlers training program.(Nanaware Balkrishna
Dattatray,2016)
Abu-Madi MA et al. surveyed intestinal parasitic infections among
recently arrived immigrant workers in Qatar destined for employment in
food handling occupations and seven species were detected among them.
The highest overall prevalence of T.trichiura was among females from the
Philippines. Those from the Indian sub-continent and the Philippines
were more likely to carry hookworms. Takizawa MD et al. reported the
occurrence of enteroparasites among food handlers in the city of
Cascavel, Brazil and reported positive fecal samples of 131 handlers.
Endolimax nana was the predominant species, followed by Enatmoeba coli,
Blastocystis hominis, Enatmoeba histolytica/dispar, and Giardia
duodenalis. Helminth infections were less common than protozoan
infections. Improper hygiene and sanitation conditions were indicated by
overall occurence of enteroparasites. (Nanaware Balkrishna
Dattatray,2016)

25
 In another study conducted by Farnaz Kheirandish, et al.(2014)
among food handlers in Western Iran, parasitic infections are one of the
major problems that affect human health adversely, especially in
developing countries. In this study 210 people from all of the fast food
shops, restaurants, and roast meat outlets of Khorramabad(Western Iran)
and all of the staff employed by them were selected through a census and
their stools were examined for the presence of parasites
The results showed 19 stool specimens that tested positive for
different intestinal parasites. Giardia lamblia was included in these
intestinal parasites. There was a significant difference between the
presence of a valid health card, awareness of transmission of intestinal
parasites, and participation in training courses in environmental health
with intestinal parasites. Several strategies are recommended in order
to control parasitic infection in food handlers such as stool
examinations every three months, public education, application of health
regulations, controlling the validity of health cards and training on
parasitic information transmission. In this regard, programs targeting
food handlers need to be developed based on the findings of the present
study since parasitic transmission could be via food handlers which is a
common problem worldwide.
Food-handlers with poor personal hygiene and dirty habits could be
potential sources of infection due to pathogenic microorganisms. Faecal
samples of 197 food-handlers were collected of both sexes working in the
hostel mess and canteen of Kasturba Medical College and Hospital,
Mangalore for a period of one year to detect the intestinal protozoan
and helminthic parasites in the stool samples of food handlers and to
correlate parasitic infection levels with hygiene and educational level
Materials and Methods. Among the 197 food-handlers included in the
study, 83 were females and 114 were males. In the stool samples tested,
there were no RBC, ova, trophozoites, or cyst. Pus cells were found only
in 18 samples but there is nothing found positive for protozoan cysts
and helminthic ova. The findings highlight that food-handlers working in
the institution have good health education and have good personal
hygiene. Moreover personal protective equipment and good care while
handling food is done by the food-handlers. (Roli Solanki et al. 2014)
26
 CHAPTER III
METHODOLOGY
Research Design
Descriptive correlational research design will be utilized in this
study to gather data from the chosen respondents. The descriptive design
will be utilized to gather the demographic, socioeconomic, and health-
seeking profile of the respondents and to assess their level of
knowledge, attitudes, and practices on intestinal parasitic infection.
On the other hand, the correlational design will be used to establish
the association of the respondents’ knowledge to their attitudes and
practices on intestinal parasitic infection.

Locale and Respondents of the study

Locale of the Study
This study will be conducted in Bulanao, Tabuk City, Kalinga . The
respondent will be the food handlers around Bulanao. The researchers
choose the place of implementation because it is one of the area in the
city where food businesses are most thriving.

Respondents of the Study

The respondents in this study will include food handlers in
Bulanao, Tabuk City, Kalinga. The said respondents are those who work in
catering and preparing foods. They are selected based on the fact that
they are the ones who handle foods for consumers or customers.

Sampling Design
This study will employ simple random sampling in choosing the
respondents. (10) different food establishments around Bulanao, Tabuk

27
City, Kalinga will be selected. Restaurants and franchised food
establishments’ food handlers will be selected. From these, the
respondent food handlers will be randomly selected to meet the computed
sample size. To generate sufficient information, the sample size will be
determined using Cochran's formula.
The values for the Z will be set at 1.96 (confidence level is 95%);
the proportion p at 0.50; q (which is equal to 1-p)at 0.50; n is the
computed sample size, and e is the margin of error (expressed as a
decimal). An additional 20% of the sample size will be added in
consideration to a possible decreased return of questionnaires by the
respondents. A sample size n of 278 was computed.

Data Gathering Tools

The researchers adopted the research questionnaire of B. Ulusoy,
Nurdan Colakoglu 2018, What do they know about food safety? A
questionnaire survey on food safety knowledge of kitchen employees in
Istanbul. Lack of hygiene knowledge and perception of food handlers play
a big role in the outbreak. The purpose of this study was to evaluate
knowledge and awareness of food handlers with regard to food safety.
The questionnaire is a set of orderly arranged questions carefully
prepared to answer by a group of people designed to collect facts and
information. The question asked is based on the research objectives. The
questionnaire will be conducted to the food handlers in Bulanao, Tabuk
City, Kalinga.

Data Analysis

28
 A set of structured questionnaires from the internet will be
utilized. Translation of the questionnaire into the Tagalog dialect and
back-translation will be done next. Securance of ethics clearance will
also be done.
The researchers will then make a request to the Office of the Mayor
of Tabuk City to conduct the study in the City, Bulanao, Tabuk City in
particular. After approval, a number of food establishments will be
obtained from the city office. From there, the researchers will randomly
select eligible food establishments in the city, particularly in
Barangay Bulanao Centro and Barangay Bulanao Norte, Tabuk City. After
selection, an endorsement to the food establishment managers of the
chosen food establishments will be requested. After the collection of
the answered questionnaires, results will undergo statistical analysis
and the research paper will then be finalized.

Statistical Treatment
For data processing and statistical analysis we will make use of
the Statistical Package for the Social Sciences (SPSS). On the analysis
of the profile of the respondents in terms of demographic profile, we
will make use of frequency and percentage distribution. For the level of
knowledge of the respondents on parasitic intestinal infection along
with the signs and symptoms, pathogens, prevention, and control, as well
as with the attitude of the respondents on parasitic infection, it will
be analyzed by mean and standard deviation. As for analyzing significant
differences in the level of knowledge and attitude of the respondents on
parasitic intestinal infection when grouped according to their profile,
it will be an analysis of values. One-way ANOVA will be utilized to
determine if there were significant comparisons between the level of
knowledge and attitudes of the respondents when grouped according to
their variables.

29
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