Professional Documents
Culture Documents
43 The objective of the present study was to evaluate the development of food
46 public schools were included in the study. School meal services were
assessed
47 every three months with a checklist, which resulted in eight evaluations over
two
48 years. A program was developed and implemented in all the schools during
this
51 handlers and monitor good practices. These steps were designed to promote
53 function was observed for the school meal services general adequacy
43 The objective of the present study was to evaluate the development of food
46 public schools were included in the study. School meal services were
assessed
47 every three months with a checklist, which resulted in eight evaluations over
two
48 years. A program was developed and implemented in all the schools during
this
53 function was observed for the school meal services general adequacy
Introduction
69 to diarrhea, responsible for 2.2 million deaths every year, mainly children in
73 2006).
78 Kferstein, 1999). These factors are associated with human development and
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83 related to several outbreak cases (Howes, McEwan, Griffiths & Harris, 1996;
84 Greig, Todd, Bartleson & Michaels, 2007). Outbreaks usually involve cases of
86 between raw foods and ready-to-eat foods. MANUSCRIPT In these cases, food
handlers are
90 good practices for food handling and that they use these practices in their
work
93 Salay & Proenca, 2011). However, Ehiri, Morris and McEwen (1997) reported
96 workplace. ACCEPTED Rennie (1994) stated that knowledge alone does not
result in
98 programs was also observed in other studies, which indicates that knowledge
99 and practice are not always associated (Cook & Casey, 1979; Park, Kwak &
100 Chang, 2010). This theory may be even more consistent than is observed in
the
101 literature, as scientific bias may cause articles that report negative results or
103 2011).
104 Therefore, new methods to promote good practices in food service are
105 needed to guarantee the quality of food provided. This assumption becomes
106 even more important in the context of school meal programs because these
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107 programs are meant to provide food to children and young people to
encourage
108 their growth and biopsychosocial development (Oliveira, Brasil & Taddei,
2008).
109 One of the most important public policies of the Brazilian federal
111 meals, through the NSFP (National School Feeding Program). The program
112 began in 1955 and over the years changes have occurred in its management
113 until it was established, in 1979, as the NSFP. Currently this program
provides,
114 through transfer of financial resources, the food supply for all students (from
day
115 care centers, elementary schools, high schools and general education for
youth
117 45.6 million of school meals are served every day in Brazil (Peixinho, 2013).
118 Brazils Good Manufacturing Practices (GMP) law does not specifically
120 considered that school kitchens are, generally, adapted rooms or similar to
121 home kitchens, resulting in great difficulty in following GMP laws (Oliveira,
Brasil
122 & Taddei, 2008). Thus, this program deserves special attention in relation to
123 food handling and the risks the ready-to-eat food can pose to students health
if
125 The objective of the present study was to evaluate trends in sanitation
126 and hygiene conditions within school meal services during the application of
a
128 triad.
2. Methods
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131 The present study included all public schools (n=68) of a highly
133 Development Index (UNDP, 2000). Schools participating in the study covered
all
135 elementary, middle and high schools for young people and adults. A total of
365
136 food handlers participated in the intervention and were distributed among
the
138 None of the school meal services had implemented the Hazard Analysis
139 and Critical Control Points (HACCP) program before the intervention.
140 MANUSCRIPT
143 Brazil, including CVS-18 (So Paulo, 2008), RDC 216 (Brazil, 2004) and CVS-6
144 (So Paulo, 1999), and on the food standards present in the Codex
145 Alimentarius (2003). The checklist contained ninety-five items divided into
146 eleven thematic areas: area one - receipt, containing six questions; area two -
149 containing four questions; area five - pest control management, containing
two
150 questions; area six - controls and records, containing four questions; area
151 seven - waste management, containing six questions; area eight health and
152 safety of employees, containing three questions; area nine - water control,
153 containing four questions; area ten - equipment and utensils, containing
twelve
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154 questions and area eleven - structure and buildings, containing fourteen
155 questions. The checklist questions were given a score of one point for
compliant
157 Trained nutritionists applied the list MANUSCRIPT to all schools participating
in the
158 study, thereby providing a diagnosis of the sanitation and hygiene conditions
of
159 the school meal services. This diagnosis stage was identified as time zero (t0)
161 After applying the checklist, fitness scores were calculated for each
162 thematic area. The scores were calculated as the number of points achieved
in
163 the thematic area divided by the maximum number of points possible for that
164 particular area and then converted into a percentage. The same procedure
was
165 followed to generate an overall adequacy score. This variable included all
166 scores ACCEPTED obtained across the ninety-five items and corresponded to
a mean
168 After discussing the strengths and weaknesses observed in each school
171 same checklist used in the diagnostic stage. The checklist was applied every
172 three months, for a total of eight evaluations performed over a two-year
period
173 (t0, t1, t2, t3, t4, t5, t6 and t7). The purpose of this application was to
monitor
174 the behavior of the scores of each thematic area and the total scores of
school
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179 concepts presented in other studies. The knowledge, attitude and practice
triad
180 serves as the central axis of the intervention MANUSCRIPT program (Bas,
Ersun & Kivanc,
181 2006; Sharif & Al-Malki, 2010) and the program evaluation uses hybrid
models
183 Gagn, 2011); the program also includes scheduled monitoring of good
184 practices (Bader, Blonder, Henriksen & Strong, 1979) and motivation of food
189 on improving ACCEPTED knowledge, which was held every six months; 2)
good practices
191 and to align practices, every three months and 3) weekly visits to all school
192 kitchens to monitor action plans and motivate food handlers. The first and
193 second stages were conducted by nutritionists outside of the school meal
194 services (external assessment and intervention) and the third stage was
195 conducted by trained tutors and staff from the municipality (internal
assessment
198 training included three breaks for meals. These trainings were conducted in
199 classrooms with a maximum of thirty food handlers in each group. They
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202 pest control, waste management, food handlers health and safety,
204 the milk dispensary, records and controls, MANUSCRIPT quality assurance,
procedures for
205 freezing goods, sampling and interpersonal relationships. All training topics
206 were selected based on the results obtained from the assessments carried
out
207 with the school meal services. Food handlers were given handouts and
209 provided the instruction at this stage. At the end of the training, all food
handlers
210 were given an assessment with questions about the topics covered.
211 The second stage of the intervention, which corresponds to the action
212 plan, was planned and performed individually and in situ within the school
meal
213 services by a team from outside the municipality, during the same week in
which
214 the quarterly ACCEPTED evaluation was held. The aim of this stage was to
correct specific
215 inadequacies observed in each school kitchen. During this stage,
inadequacies 216 regarding good practices were noted for all food handlers and
targets were
221 handlers practices and goals for the next quarterly review. Order requests
were
222 submitted to the school board and the school meal services coordinator when
223 structural problems were noted, equipment and utensils were needed or any
224 other factor regarding management and/or use of resources was identified.
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225 The third stage included an individualized weekly visit to each school
226 meal service performed by tutors. These tutors were food handlers who had
227 been trained to develop monitoring for school meal services and were
therefore 228 considered internal evaluators. During this MANUSCRIPT stage,
food handlers were invited by
229 the tutors to report any difficulties in the workplace and to make suggestions
for
230 improvement of the sanitation practices. This stage was also designed to
231 monitor the progress of action plans by evaluating the adequacy of the
233 At the end of each quarterly assessment, a report was issued and copies
234 were sent to the municipalitys school food sector for referrals relating to
237 Trend ACCEPTED analysis using regression models was chosen for the data
238 analysis. This analysis facilitated evaluation of the behavior of the dependent
239 variable (Y), the good practices adequacy percentage, in relation to the
240 evaluation periods (X). A total of eight evaluations occurred every three
months.
241 First, scatter diagrams were made showing the relationship between the
242 adequacy percentages and the time variables to verify the type of
relationship
244 The time variable (X) was centralized, therefore "X-11.5" was used,
245 where 11.5 is the mean time in months of the study period. This procedure
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247 First, the simplest linear regression model was tested (Y = 0 + 1X).
248 Based on the function identified in the scatter diagram, models of higher
orders
251 The model that showed greater statistical significance and normal
252 residuals was considered the best-fit. Models with p<0.05 were considered
253 significant.
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257 assessment points for each of the sixty- eight school meal service research
258 participants.
261 The first value of the equation is the mean adequacy percentage followed by
its
263 (r) and significance (p) of each model are also listed.
264 An ascending linear function was identified for the overall adequacy
265 percentage, showing that the intervention strategy used explains 87% of the
266 improvement in good practice scores over the observation period (p <0.01).
267 Therefore, the intervention strategy tends to bring food services into line with
268 health legislation. Bader et al. (1978) evaluated food service establishments
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269 and showed that sites that received four health inspections per year obtained
270 final good practice scores 47% higher than sites that only had one inspection
271 performed. This result shows that systematic and frequent visits help in the
274 Figure 2 shows the regression models of the thematic area variables
275 over the eight ratings. Reduction in the overall adequacy percentage in
month
276 ten (fourth assessment) was observed (Figure 2A). In addition to the overall
278 equipment and utensils, buildings and facilities (Figure 2A), processes and
279 procedures, controls and records (Figure 2B) and storage (Figure 2C). These
280 adequacy percentage reductions coincided with holiday periods for the food
281 handlers. Absence from the workplace most likely led handlers to resume
282 incorrect ACCEPTED practices that had previously been corrected. Therefore,
interventions
283 should be continued and strengthened especially after holiday periods to
avoid
284 inadequacies. Furnari, Molino, Bruno, Quaranta, Laurenti and Ricciardi (2002)
285 observed that ongoing training reduced the resistance of food handlers to
using
287 When the thematic areas were analyzed separately, positive increments
288 were observed in the following areas: buildings and facilities (p=0.01),
291 (p<0.01) and equipment and utensils (p<0.05). In this case, the positive
effect
292 was demonstrated with linear and coefficient of determination models above
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293 0.50 for all tests. This indicates that up to 50% of the variation between
295 intervention.
297 controls and records thematic area (Figure 2B). This model indicates that
298 despite positive development, in the period between the second and fourth
300 completion of temperature control sheets and labels with usage information
and
301 food validity. Lockis, Cruz, Walter Faria, Granato & Sant'Ana (2011), in a cross-
302 sectional study of school meal services, observed that the filing of records
and
303 controls was the third largest inadequacy observed with respect to good
304 practices. These results show that food handlers may exhibit resistance to the
305 completion of records and controls, but the intervention proposed here
306 improved ACCEPTED adequacy in this area by 33.4% over two years.
308 practices have been observed in different contexts, such as hospitals (El
Derea,
309 Salem, Fawzi & Abdel Azeem, 2008), street food vending (Choudhury,
Mahanta,
310 Goswami & Mazumder, 2011), small businesses (Bush, Paleo, Baker, Dewey,
311 Toktogonova & Cornelio, 2009) and with those responsible for food services
312 (Kassa, Silverman & Baroudi, 2010). However, no studies have been
conducted
313 using strategies with school meal services that demonstrate a positive effect
on
314 practices.
315 The thematic areas of integrated pest management (Figure 2B) and
316 health and safety of employees (Figure 2D) reached nearly 100% adequacy,
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317 with 98.6% and 95.3% adequacy, respectively. For integrated pest
318 management, the most influential positive factor was adjustment in the
319 frequency of chemical control use and the archiving of probative documents.
320 About the thematic area of health and safety MANUSCRIPT of employees, the
training
324 (p<0.01), and the receiving and storing blocks did not change significantly
325 between assessments. Handlers most likely failed to prioritize these activities
in
326 relation to others because they were identified as low risk for foodborne
327 disease. Internal evaluators may also not have prioritized these steps, failing
to
329 Such ACCEPTED factors depend on the perception of risk involved. Food
handlers
331 performed with school meal services (Da Cunha, Stedefeldt & De Rosso,
2012).
333 adequacy percentages for waste management have also been reported
(Lockis
335 Vidal Jr., Silva & Huttner, 2011) and may be a reflection of the low perception
of
339 evaluation. This combination provides results closer to reality and facilitates
the
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340 planning of interventions. Internal assessment provides deep insight into the
345 more effectively (Minnett, 1999). The external evaluator has greater access
to
346 information because people tend to be more sincere about their problems
with
347 people who are not involved in their daily routine (Conley-Tyler, 2005).
348 Additionally, the external evaluator more easily identifies errors inserted into
349 work routines, evaluating the service with greater objectivity and reduced
bias,
353 work together ACCEPTED with the World Food Programme (WFP) of the Food
and
355 feeding programs in several countries in Latin America, the Caribbean and
357 improvement of materials to ensure food security cannot only benefit the
358 Brazilian school feeding program, but also help other countries that
cooperate
361 4. Conclusion
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362 The systematic intervention strategy proposed by the present study was
363 effective in improving school meal services adequacy in terms of food
service
365 The strategy was important for the MANUSCRIPT improvement of sanitation
and
366 hygiene conditions regarding structural issues, controls and records and food
367 handling activities, all of which are essential for quality assurance. Activities
368 before and after food handling, such as raw material receiving, storage and
369 waste disposal, were not prioritized by food handlers. Handlers most likely
370 identified such actions as low risk for food contamination. However, this
372 Another important finding observed in this study was the reduction in the
373 overall adequacy percentage after food handlers' holiday periods. Permanent
377 successful ones, should not be observed as a panacea for problems involving
379 in food service units, and those responsible must carry out constant
monitoring,
380 food handler motivation, structural reforms and quality assurance of food and
382 The performance of this strategy may be observed in other food service
383 areas, such as restaurants, hospitals and even the street food.