Food Control 34 (2013) 662e667

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Food Control
journal homepage: www.elsevier.com/locate/foodcont

Improvement of food safety in school meal service during a long-term

intervention period: a strategy based on the knowledge, attitude
and practice triad
Diogo Thimoteo da Cunha a,1, Rose Magda Fiorotti b, 2, Juliana Garcia Baldasso c, 3,
Maricy de Sousa c, 3, Nathália Moretti Fontanezi c, 3, Simone Caivano c, 3, Elke Stedefeldt a,1,
Veridiana Vera de Rosso a,1, Maria Cristina Rubim Camargo c, *, 3
a
GeQual e Study Group of Food Quality, Federal University of São Paulo, Santos, Brazil
b
Prefeitura Municipal de São Caetano do Sul, São Caetano do Sul, Brazil
c
Instituto Nutra e Viva, Santana de Parnaíba city, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: The objective of the present study was to evaluate the development of food safety scores in school meal
Received 18 September 2012 services during the application of a systematic intervention based on the knowledge, attitude and
Received in revised form practice triad. A total of 68 public schools were included in the study. School meal services were assessed
27 May 2013
every three months with a checklist, which resulted in eight evaluations over two years. A program was
Accepted 4 June 2013
developed and implemented in all the schools during this period that was comprised of three steps: 1)
theoretical training, 2) implementation of action plans in situ and 3) weekly visits to motivate food
Keywords:
handlers and monitor good practices. These steps were designed to promote changes in the attitudes and
Training
Food safety
practices of food handlers. An ascending linear function was observed for the school meal services’
Food service general adequacy percentage over time. Positive developments were also observed regarding buildings
Food safety management and facilities, processes and procedures, distribution of meals, integrated pest management, water
Time series control, controls and records, health and safety of employees and equipment and utensils. Our results
School meals suggest that the proposed intervention strategy performs well in making school meal services conform
to good practices and that strategies in this context should be permanent and continuous.
Ó 2013 Elsevier Ltd. All rights reserved.

1. Introduction
Foodborne diseases are considered to be an emerging problem
and are currently a subject of major concern for the governments of
various countries throughout the world. Affecting both developed
and developing countries, every individual in the world is at risk of
foodborne disease (WHO, 2008).
Food- and water-borne diseases contribute significantly to
mortality due to diarrhea, responsible for 2.2 million deaths every
year, mainly children in developing countries (WHO, 2008). How-
ever, the magnitude of the problem is believed to be even greater
* Corresponding author. Tel.: þ55 11 3044 0693; fax: þ55 11 4192 2363.
E-mail address: rubim@nutraeviva.com.br (M.C.R. Camargo).
1
Address: Ana Costa avenue, 95, Vila Mathias, 11010-001, Santos city, SP, Brazil.
2
Address: Fernando Simonsen avenue, 566, Bairro Cerâmica, 09540-230, São
Caetano do Sul city, SP, Brazil.
3
Address: Alameda Brilhante, 673, Alphaville, 06540-115, Santana de Parnaíba
city, SP, Brazil.
due to underreporting and the lack of full health monitoring sys-
tems, even in developed countries (Seaman & Eves, 2006).
Several factors contribute to the incidence of foodborne disease,
including population growth, growth of highly vulnerable popu-
lation groups, lack of basic sanitation, increased food production
and distribution and changes in consumer behavior toward a
preference for high-risk foods (Motarjemi & Käferstein, 1999).
These factors are associated with human development and society
rather than directly associated with food handlers.
Nonetheless, studies report that the inadequate handling of food
is considered the main causal mechanism of foodborne disease and
is directly related to several outbreak cases (Greig, Todd, Bartleson,
& Michaels, 2007; Howes, McEwan, Griffiths, & Harris, 1996). Out-
breaks usually involve cases of inadequate cooking temperatures
and storage and cross-contamination between raw foods and
ready-to-eat foods. In these cases, food handlers are estimated to be
responsible for 97% of foodborne outbreaks (Egan et al., 2007).
Thus, strategies should be employed to ensure that food han-
dlers know good practices for food handling and that they use these

0956-7135/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.foodcont.2013.06.003
 D.T. da Cunha et al. / Food Control 34 (2013) 662e667
practices in their work environment. The most widely used strategy
is training, which is considered to be an important method to in-
crease knowledge and skills (Medeiros, Cavalli, Salay, & Proenca,
2011). However, Ehiri, Morris, and McEwen (1994) reported that
Good Hygiene Practice training, which involves only scientific
communication, is not an effective strategy for changing practices
in the workplace. Rennie (1994) stated that knowledge alone does
not result in changes in food hygiene practices. Failure to change
behavior following training programs was also observed in other
studies, which indicates that knowledge and practice are not al-
ways associated (Cook & Casey, 1979; Park, Kwak, & Chang, 2010).
This theory may be even more consistent than is observed in the
literature, as scientific bias may cause articles that report negative
results or intervention failures to remain unpublished (Dirnagl &
Lauritzen, 2010; Schooler, 2011).
Therefore, new methods to promote good practices in food
service are needed to guarantee the quality of food provided. This
assumption becomes even more important in the context of
school meal programs because these programs are meant to
provide food to children and young people to encourage their
growth and biopsychosocial development (Oliveira, Brasil, &
Taddei, 2008).
One of the most important public policies of the Brazilian fed-
eral government to ensure the health of the population is the
provision of school meals, through the NSFP (National School
Feeding Program). The program began in 1955 and over the years
changes have occurred in its management until it was established,
in 1979, as the NSFP. Currently this program provides, through
transfer of financial resources, the food supply for all students (from
day care centers, elementary schools, high schools and general
education for youth and adults) enrolled in public and philan-
thropic schools in Brazil. Approximately 45.6 million of school
meals are served every day in Brazil (Peixinho, 2013).
Brazil’s Good Manufacturing Practices (GMP) law does not
specifically address school kitchens, ruled by laws applied to
general food services. It must be considered that school kitchens
are, generally, adapted rooms or similar to home kitchens, resulting
in great difficulty in following GMP laws (Oliveira et al., 2008).
Thus, this program deserves special attention in relation to food
handling and the risks the ready-to-eat food can pose to students’
health if food is mishandled.
The objective of the present study was to evaluate trends in
sanitation and hygiene conditions within school meal services
during the application of a systematic intervention program based
on the knowledge, attitude and practice triad.
2. Methods
The present study included all public schools (n ¼ 68) of a highly
developed municipality of São Paulo (Brazil) with a 0.8340 Human
Development Index (UNDP, 2000). Schools participating in the
study covered all age groups involved in basic education, including
kindergarten, preschool, elementary, middle and high schools for
young people and adults. A total of 365 food handlers participated
in the intervention and were distributed among the school meal
services being evaluated.
None of the school meal services had implemented the Hazard
Analysis and Critical Control Points (HACCP) program before the
intervention.
2.1. Checklist and application
A good practice checklist was developed based on current legis-
lation in Brazil, including CVS-18 (São Paulo, 2008), RDC 216 (Brazil,
2004) and CVS-6 (São Paulo, 1999), and on the food standards
663
present in the Codex Alimentarius (2003). The checklist contained
ninety-five items divided into eleven thematic areas: area one e
receipt, containing six questions; area two e storage, containing
seventeen questions; area three e processes and procedures, con-
taining twenty questions; area four e distribution of meals, con-
taining four questions; area five e pest control management,
containing two questions; area six e controls and records, containing
four questions; area seven e waste management, containing six
questions; area eight e health and safety of employees, containing
three questions; area nine e water control, containing four ques-
tions; area ten e equipment and utensils, containing twelve ques-
tions and area eleven e structure and buildings, containing fourteen
questions. The checklist questions were given a score of one point for
compliant conditions and zero for non-compliant conditions.
Trained nutritionists applied the list to all schools participating
in the study, thereby providing a diagnosis of the sanitation and
hygiene conditions of the school meal services. This diagnosis stage
was identified as time zero (t0) of the intervention.
After applying the checklist, fitness scores were calculated for
each thematic area. The scores were calculated as the number of
points achieved in the thematic area divided by the maximum
number of points possible for that particular area and then con-
verted into a percentage. The same procedure was followed to
generate an overall adequacy score. This variable included all scores
obtained across the ninety-five items and corresponded to a mean
adequacy for all thematic areas.
After discussing the strengths and weaknesses observed in each
school meal service, an intervention program was proposed.
This intervention program was monitored by repeated applica-
tions of the same checklist used in the diagnostic stage. The
checklist was applied every three months, for a total of eight
evaluations performed over a two-year period (t0, t1, t2, t3, t4, t5, t6
and t7). The purpose of this application was to monitor the
behavior of the scores of each thematic area and the total scores
of school meal services after the intervention program was
implemented.
2.2. Intervention program
The proposed intervention program provides a new form of
intervention to promote good practices in food service as it com-
bines strategies and concepts presented in other studies. The
knowledge, attitude and practice triad serves as the central axis of
the intervention program (Bas, Ersun, & Kivanc, 2006; Sharif & Al-
Malki, 2010) and the program evaluation uses hybrid models
(combination of internal and external evaluation) (Bourgeois, Hart,
Townsend, & Gagné, 2011); the program also includes scheduled
monitoring of good practices (Bader, Blonder, Henriksen, & Strong,
1978) and motivation of food handlers (Seaman, 2010).
Systematization of the intervention model was adapted from
Seaman (2010) (Fig. 1).
The intervention consisted of three stages: 1) theoretical
training focused on improving knowledge, which was held every
six months; 2) good practices evaluation and implementation of
in situ action plans to correct nonconformities and to align
practices, every three months and 3) weekly visits to all school
kitchens to monitor action plans and motivate food handlers.
The first and second stages were conducted by nutritionists
outside of the school meal services (external assessment and
intervention) and the third stage was conducted by trained tutors
and staff from the municipality (internal assessment and
intervention).
A total of five 12-h theoretical trainings were performed. Each
training included three breaks for meals. These trainings were
conducted in classrooms with a maximum of thirty food handlers
664 D.T. da Cunha et al. / Food Control 34 (2013) 662e667

Overall performance of school meal service and individual performance of food handlers

Adequate food
handling Effect of social Inadequate food
Structural practices habits, routines handling practices
adjustment and and components
purchase of
materials and
equipment Food handlers’ intentions to change attitudes

Requesting 1) Training 2) In situ 3) Monitoring

structural focused on implementation of (internal
reforms and improving action plans assessment)
purchases of knowledge focused on focused on
materials and (every 6 months) changes in motivation and
equipment practice maintaining changes
(Every 3 months) in practice

Proposal for intervention

Document with positive and negative aspects of the school meal services

Application of checklist (external evaluation)

Fig. 1. Flow of systematic intervention program based on the knowledge, attitude and practice triad applied to school meal services.

in each group. They included dialogical lectures and projected
presentations on the following issues: food contamination,
receiving, storage, processes and production, distribution, pest
control, waste management, food handlers’ health and safety,
environmental hygiene, equipment and utensils, visitor pro-
cedures, operation of the milk dispensary, records and controls,
quality assurance, procedures for freezing goods, sampling and
interpersonal relationships. All training topics were selected based
on the results obtained from the assessments carried out with the
school meal services. Food handlers were given handouts and
materials on the topics covered in training. External evaluating
nutritionists provided the instruction at this stage. At the end of the
training, all food handlers were given an assessment with questions
about the topics covered.
The second stage of the intervention, which corresponds to the
action plan, was planned and performed individually and in situ
within the school meal services by a team from outside the mu-
nicipality, during the same week in which the quarterly evaluation
was held. The aim of this stage was to correct specific inadequacies
observed in each school kitchen. During this stage, inadequacies
regarding good practices were noted for all food handlers and
targets were drawn up for the next evaluation to be implemented
in three months.
The action plan consisted of the following items: identification
of inadequacies, determination of corrective actions, individual
orientation of the food handlers with the demonstration of correct
procedures, observation of the handlers’ practices and goals for the
next quarterly review. Order requests were submitted to the school
board and the school meal services coordinator when structural
problems were noted, equipment and utensils were needed or any
other factor regarding management and/or use of resources was
identified.
The third stage included an individualized weekly visit to each
school meal service performed by tutors. These tutors were food
handlers who had been trained to develop monitoring for school
meal services and were therefore considered internal evaluators.
During this stage, food handlers were invited by the tutors to report
any difficulties in the workplace and to make suggestions for
improvement of the sanitation practices. This stage was also
designed to monitor the progress of action plans by evaluating the
adequacy of the procedures performed.
At the end of each quarterly assessment, a report was issued and
copies were sent to the municipality’s school food sector for re-
ferrals relating to management, procurement and reforms.
2.3. Data analysis
Trend analysis using regression models was chosen for the data
analysis. This analysis facilitated evaluation of the behavior of the
dependent variable (Y), the good practices adequacy percentage, in
relation to the evaluation periods (X). A total of eight evaluations
occurred every three months.
First, scatter diagrams were made showing the relationship
between the adequacy percentages and the time variables to verify
the type of relationship between these variables.
The time variable (X) was centralized, therefore “X-11.5” was
used, where 11.5 is the mean time in months of the study period.
This procedure prevents collinearity between terms of the regres-
sion equation.
First, the simplest linear regression model was tested
(Y ¼ b0 þ b1X). Based on the function identified in the scatter dia-
gram, models of higher orders were also tested, including
second degree (Y ¼ b0 þ b1X þ b2X2), third degree
(Y ¼ b0 þ b1X þ b2X2 þ b3X3) and exponential (ln (Y) ¼ ln
(b0) þ (b1X)) models.
The model that showed greater statistical significance and
normal residuals was considered the best-fit. Models with p < 0.05
were considered significant.
 D.T. da Cunha et al. / Food Control 34 (2013) 662e667 665

3. Results and discussion effect was demonstrated with linear and coefficient of determina-
tion models above 0.50 for all tests. This indicates that up to 50% of
A total of 512 evaluations were performed, corresponding to the variation between evaluations can be explained as a function of
eight assessment points for each of the sixty-eight school meal time, and therefore, of the intervention.
service research participants. Using a quadratic model, favorable development was observed
in the controls and records thematic area (Fig. 2B). This model in-
3.1. Evaluation of the intervention program dicates that despite positive development, in the period between
the second and fourth assessment, there was a reduction in correct
Table 1 shows the regression models for each thematic area practices in relation to the completion of temperature control
evaluated. The first value of the equation is the mean adequacy sheets and labels with usage information and food validity. Lockis,
percentage followed by its increment (positive or negative) after Cruz, Walter Faria, Granato, & Sant’Ana (2011), in a cross-sectional
each intervention; the explanatory power (r2) and significance (p) study of school meal services, observed that the filing of records
of each model are also listed. and controls was the third largest inadequacy observed with
An ascending linear function was identified for the overall ad- respect to good practices. These results show that food handlers
equacy percentage, showing that the intervention strategy used may exhibit resistance to the completion of records and controls,
explains 87% of the improvement in good practice scores over the but the intervention proposed here improved adequacy in this area
observation period (p < 0.01). Therefore, the intervention strategy by 33.4% over two years.
tends to bring food services into line with health legislation. Bader Positive effects of food safety-related interventions in terms of
et al. (1978) evaluated food service establishments and showed that changing practices have been observed in different contexts, such
sites that received four health inspections per year obtained final as hospitals (El Derea, Salem, Fawzi, & Abdel Azeem, 2008), street
good practice scores 47% higher than sites that only had one in- food vending (Choudhury, Mahanta, Goswami, & Mazumder, 2011),
spection performed. This result shows that systematic and frequent small businesses (Bush et al., 2009) and with those responsible for
visits help in the motivation and monitoring of food services; food services (Kassa, Silverman, & Baroudi, 2010). However, no
therefore, they improve good hygiene practices. Has been recently studies have been conducted using strategies with school meal
published a specific good practice checklist for Brazilian school services that demonstrate a positive effect on practices.
meal services. This tool can be an option to assess and monitor the The thematic areas of integrated pest management (Fig. 2B) and
food safety on this environment (Stedefeldt, Cunha, Silva Junior, health and safety of employees (Fig. 2D) reached nearly 100% ad-
Oliveira, & Silva, 2013). equacy, with 98.6% and 95.3% adequacy, respectively. For integrated
Fig. 2 shows the regression models of the thematic area vari- pest management, the most influential positive factor was adjust-
ables over the eight ratings. Reduction in the overall adequacy ment in the frequency of chemical control use and the archiving of
percentage in month ten (fourth assessment) was observed probative documents. About the thematic area of health and safety
(Fig. 2A). In addition to the overall percentage, small reductions of employees, the training adequacy, purchasing of utensils and
occurred in the following thematic areas: equipment and utensils, frequency of medical exams contributed to the achieved adequacy.
buildings and facilities (Fig. 2A), processes and procedures, controls The waste management thematic area showed a negative
and records (Fig. 2B) and storage (Fig. 2C). These adequacy per- increment (p < 0.01), and the receiving and storing blocks did not
centage reductions coincided with holiday periods for the food change significantly between assessments. Handlers most likely
handlers. Absence from the workplace most likely led handlers to failed to prioritize these activities in relation to others because they
resume incorrect practices that had previously been corrected. were identified as low risk for foodborne disease. Internal evalua-
Therefore, interventions should be continued and strengthened tors may also not have prioritized these steps, failing to monitor
especially after holiday periods to avoid inadequacies. Furnari et al. them and propose corrections.
(2002) observed that ongoing training reduced the resistance of Such factors depend on the perception of risk involved. Food
food handlers to using food handling knowledge in their practice. handlers were shown to have reasonable perception of foodborne
When the thematic areas were analyzed separately, positive illness risks in a study performed with school meal services (Da
increments were observed in the following areas: buildings and Cunha, Stedefeldt, & De Rosso, 2012). This perception increased
facilities (p ¼ 0.01), processes and procedures (p < 0.01), meal with participation in mandatory training. Lower adequacy per-
distribution (p < 0.01), integrated pest management (p < 0.01), centages for waste management have also been reported (Cardoso
health and safety of employees (p < 0.01), water control (p < 0.01) et al., 2011; Lockis et al., 2011) and may be a reflection of the low
and equipment and utensils (p < 0.05). In this case, the positive perception of risk for this activity by food handlers in these
locations.
Table 1
Regression equations, explanatory power and significance of the development of the 3.2. Practical implications
overall good practices adequacy percentage and adequacy percentage of the the-
matic areas evaluated. The intervention strategy used combined internal and external
Thematic areas Model r2 p evaluation. This combination provides results closer to reality and
facilitates the planning of interventions. Internal assessment pro-
Buildings and facilities y ¼ 50.83 þ 0.903x 0.79 <0.01
Receipt y ¼ 63.11 þ 0.140x 0.007 0.842
vides deep insight into the organization and work, facilitating
Storage y ¼ 78.36 þ 0.045x 0.04 0.618 decision-making (Bourgeois et al. 2011). The internal evaluator
Processes and procedures y ¼ 66.82 þ 0.328x 0.83 < 0.001 tends to understand cultural and political motivations behind
Distribution of meals y ¼ 45.04 þ 1.955x 0.88 <0.001 behavior in the service (Conley-Tyler, 2005). Moreover, the evalu-
Integrated pest management y ¼ 83.79 þ 1.845x 0.76 <0.01
ator understands well the nature of the results, and thus the results
Controls and Records y ¼ 20.75 þ 1.610x þ 0.122x2 0.91 <0.01
Waste Management y ¼ 47.55  0.816x 0.88 <0.001 can be used more effectively (Minnett, 1999). The external evalu-
Health and safety of employees y ¼ 88.18 þ 1.264x 0.68 <0.01 ator has greater access to information because people tend to be
Water control y ¼ 40.68 þ 2.202x 0.97 <0.001 more sincere about their problems with people who are not
Equipment and utensils y ¼ 77.78 þ 0.599x 0.50 <0.05 involved in their daily routine (Conley-Tyler, 2005). Additionally,
Overall adequacy percentage y ¼ 64.77 þ 0.572x 0.87 <0.001
the external evaluator more easily identifies errors inserted into
666 D.T. da Cunha et al. / Food Control 34 (2013) 662e667
Fig. 2. Regression models for the overall good practices score and thematic areas monitored during application of the intervention model for school meal services.
work routines, evaluating the service with greater objectivity and
reduced bias, which is fundamental, especially with regards to
summative assessments (Bourgeois et al., 2011; Conley-Tyler,
2005).
Another important practical implication is that in 2007 Brazil
began to work together with the World Food Programme (WFP) of
the Food and Agriculture Organization of the United Nations (FAO)
in the structuring of school feeding programs in several countries in
Latin America, the Caribbean and Africa (Organization of American
States, 2008). The development and improvement of materials to
ensure food security cannot only benefit the Brazilian school
feeding program, but also help other countries that cooperate with
Brazil.
4. Conclusion
The systematic intervention strategy proposed by the present
study was effective in improving school meal services’ adequacy in
terms of food service hygiene laws.
The strategy was important for the improvement of sanitation
and hygiene conditions regarding structural issues, controls and
records and food handling activities, all of which are essential for
quality assurance. Activities before and after food handling, such as
raw material receiving, storage and waste disposal, were not
prioritized by food handlers. Handlers most likely identified such
actions as low risk for food contamination. However, this hypoth-
esis needs to be tested.
Another important finding observed in this study was the
reduction in the overall adequacy percentage after food handlers’
holiday periods. Permanent intervention strategies should be
prioritized with emphasis on the period after vacation periods and
sick leave.
Importantly, intervention strategies for food handlers’ practices,
even successful ones, should not be observed as a panacea for
problems involving foodborne diseases. Several aspects influence
sanitation and hygiene practices in food service units, and those
responsible must carry out constant monitoring, food handler
motivation, structural reforms and quality assurance of food and
raw materials, among other actions.
The performance of this strategy may be observed in other food
service areas, such as restaurants, hospitals and even the street
food.
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