Determinants of public health in food establishments and health status of food handlers in Addis Ababa, Ethiopia
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Date
2020-06
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Addis Ababa University
Abstract
Introduction: Globally, drinking water quality is continuously deteriorating and becoming
non-suitable for human use and well-being. That is why, above 20% of the world, population
does not have access to pure drinking water. Globally, 26% of people drink water that is, at
least occasionally, contaminated with fecal bacteria. Of all human illnesses in the developing
world, 80% are caused by biological contamination. Further, more than 33.3% of the world
population does not have access to improved sanitation. Globally, the health burden of poor
water quality, sanitation and hygiene is massive. Despite advancements in food science and
technology, food and waterborne disease remains one of the major public health problems in
the world. In many parts of low-income countries such as in Ethiopia, public health problems
associated with deterioration of food and water safety situations are much more aggravated
due to poverty and environmental related risks. Data from the previous studies indicated that
several food establishments in Addis Ababa lack safe drinking water and suffer from poor
sanitation and hygiene practices. Credible evidence from scientific literature substantiate that
inadequate sanitation and poor hygiene conditions of food establishments are the major cause
for the occurrence of food and water borne diseases. In such case, there is huge demand for
good sanitation practice and proper handling of drinking water in the food establishments. In
my view, this is the frame in which I derive the objectives for my PhD work, basically to
investigate microbial drinking water quality, sanitation and hygiene situation of food
establishments as well as health status of food handlers in Addis Ababa.
Methods: Institution based longitudinal and cross-sectional studies were conducted. Sample
sizes were calculated using a single and two population proportion formulas. Stratified,
simple random sampling techniques were employed. For this study, 250 drinking water
samples, 420 food establishments and 420 food handlers were included to assess drinking
water quality, sanitation and hygiene status of food establishments, awareness, outlook and
practice of food handlers respectively. Moreover, 1058 food handlers were included to
determine diarrheal disease and associated behavioral factors among food handlers. Data was
analyzed by SPSS version 20. A repeated–measure ANOVA, Binary Logistic Regression,
Multivariable Logistic Regression and Linear Regression Model and analysis of variance
were used for data analysis.
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Results: The longitudinal data analysis indicated that, 26.4% and 10.7% of the food
establishments drinking water had occurrence of Escherichia coli type of bacteria in the wet
and dry season respectively. The finding of the study revealed that, 3.2% and 1.6% of the
food establishments drinking water had very high health risk to customers during the wet and
dry season respectively. In the study, the mean score of fecal coli forms count pre100/ml
were found to be 7.59 and 3.12 in the wet and dry season respectively. There was statistically
significant difference between the mean values of the E. coli per 100ml between the dry and
wet season with P-value <0.00. Besides, the sanitation and hygiene status of food
establishments study revealed that, 57.4% of the food establishments were under poor
sanitation status. In the multivariable analysis, presence of trained managers on hygiene and
sanitation (AOR=6.10 with 95%CI:2.41-15.45), presence of renewed licenses (AOR=3.07
with 95% CI:1.18-7.99), absence of bureaucratic function to obtain permission to renew the
food establishment buildings (AOR=2.43 with 95%CI:1.25-4.70) and presence of at least
ten-meter distance between toilet and kitchen (AOR = 9.19, at 95% CI: 5.63 -15.02) were
associated significantly with sanitation and hygiene status of food establishments. Moreover,
the awareness, outlook and practice part of this study showed that, 55.5%, 66.1% and 60.6%
of the food handlers had good awareness, outlook and proper hygiene practices respectively.
Predictor variables like educational status and length of work experience were correlated
positively and significantly with awareness. However, being married was correlated
negatively with awareness. In addition, the diarrheal disease study result indicated that, the
two-week prevalence of diarrhea was found to be 3.4%. Further, 1.6%, 10.5%, 10.7% and
9% of the food handlers had acute watery diarrhea, cough, an infection of runny nose and
incidence of any fever respectively. Five behavioural factors including: regular hand washing
after toilet (AOR=0.13 with 95% CI: 0.024, 0.72), using toilet while wearing protective
clothes/gown (AOR=5.39 with 95% CI; 1.59, 18.32), washing glass or the material used for
drinking water every event (AOR=0.009 with 95% CI: 0.001, 0.093), habit of eating raw beef
and raw vegetables (AOR=6.27 with 95% CI: 1.89-20.78), type of toilet (AOR=4.07 with
95% CI: 0.29-6.67 were associated significantly with diarrhea.
Conclusion: Drinking water at the point of use in all food establishments were found to be
vulnerable to microbiological contamination and had a serious health risk to those who
consumes the water. The microbial load of the drinking water at the point of use differs
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between the dry and rainy seasons. The occurrences of fecal coliforms and/ or E. coli were
higher during the rainy season. It was concluded that, there was a significant time effect for
the occurrence of fecal coli form and/or E. coli. Moreover, the finding of the longitudinal
study revealed that, significant numbers of the food establishments’ drinking water had high
and very high health risk to customers both in the wet and dry season. Regarding the
sanitation and hygiene study findings, above average of the food establishments were found
to be in poor sanitation and hygiene state. In this study, many core determinant factors that
influence sanitation and hygienic status of food establishments were identified. Moreover,
assessing awareness, outlook and practice of food handlers regarding food and water safety is
a vital activity to reduce public health problems. In the study, significant number of food
handlers had poor awareness, outlook and practice towards food and water safety. There is a
call for enhancing the awareness, outlook and practice of food and water safety to achieve an
excellent practice. In addition, the study assessed the prevalence of diarrheal disease and
identifies behavioral factors associated with diarrhea. This assessment proved to be an
essential activity for reduction of community-acquired diarrheal diseases, as a significant
number of food handlers had diarrhea. Therefore, good sanitation and proper handling of
drinking water should be practiced in all food establishments. This includes effective
drinking water treatment such as disinfection, boiling and filtration should be implemented at
the food establishment level. Moreover, the government should be done continuous microbial
drinking water monitoring and evaluation to improve drinking water quality. Formal training
on sanitation and hygiene for managers of food establishments should be provided to reduce
the occurrence of food borne diseases. Besides, strong food and water safety policy, strategy
and firm regulatory actions should be promulgated to improve sanitation and hygiene status
of food establishments. The government should focus on comprehensive diarrheal disease
control strategy, including improvement of water quality, hygiene, and sanitation. Current
public health programs of Addis Ababa city administration should develop effective
approaches to promote hand washing practice and awareness creation.
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Keywords
Determinats, Public Health, Food Establishment, Health Status, Food Handlers, Addis Ababa, Ethiopia