EHJ July 2004, pages 220-222
Good hand hygiene among food handlers is one of the most effective ways to prevent micro-organisms from spreading.

Euan MacAuslan asks why accredited food hygiene certificate courses are failing to recognise its importance in food safety management and what needs to be done to improve standards It's a simple habit that requires minimal training and no special equipment yet evidence suggests too few people practise proper hand washing. In the United States, the Communicable Disease Centre has identified poor hand hygiene as the number one cause in the spread of food-borne illness.

On this side of the Atlantic, evidence paints a similar picture of bad practice in many food outlets. A Mori poll, published in the Caterer and Hotelkeeper in April 2004, indicated that of the 5,469 adults interviewed across Europe, 34 per cent would not return to a restaurant where the waiting staff had dirty fingernails or clothes.

In the UK, a Food Standards Agency catering workers hygiene survey of 1,000 workers and managers in 2002, revealed that 39 per cent of staff neglected to wash their hands after visiting the lavatory at work, and 53 per cent did not appear to wash their hands before preparing food. Why do food handlers, especially in small hospitality businesses, fail to demonstrate effective hand washing after attaining food hygiene certificates?

EDUCATION AND TRAINING

Food handlers and enforcement officers may not wash their hands properly for a number of reasons. These may include skin irritation, the inaccessibility of hand-washing facilities, a reliance on gloves, being too busy, not thinking about it, inadequate practical training and a lack of supervision.

The Department of Employment and Productivity's glossary of terms, published in 1978, describes training as "the systematic development of attitude, knowledge and skill patterns required by an individual to perform an adequately given task". And yet, the current accredited food hygiene and food safety certificate course syllabuses make no direct reference to correct hand-washing techniques or practical assessment. The questions in the examination papers only relate to personal hygiene and when or where hands should be washed. The vital questions regarding how and why are not evident. A minority may be taught about correct techniques of hand washing on these courses.

However, little consideration is made in respect of any hand-washing culture they may be faced with after returning to work. Do their managers, for example, make hand washing an accessible and feasible control measure? None of the existing hospitality or food preparation NVQs or the syllabuses for degrees in environmental health or certificate courses for potential food premises inspectors include practical training about hand-washing techniques. The emphasis of formal food hygiene training, which culminates in accredited examinations still seems to be geared towards helping the food handler gain a certificate. It does not appear to be geared necessarily towards the food handler being able to demonstrate practical application of good food hygiene or personal hygiene standards in the workplace.

Given these facts, it is difficult to pinpoint where managers, food handlers and enforcement officers receive the necessary training to demonstrate proper hand-washing techniques. In an ideal world they will have been taught at home or at school. Unfortunately, there is a generation of parents and schoolteachers who have never been taught how to wash their hands properly. It is something that is all too often taken for granted. Ofsted school inspectors never pick this up in their school assessments. During the 1980s, home economics was removed from the school curriculum. Along with it went the knowledge among teachers and future parents on how to wash hands properly.

Personal Social and Health Education (PSHE) curricula activities are starting to include more about hand hygiene. At key stages 1 and 2, personal hygiene, including hand hygiene, is coming back into the classroom. The Education Act 2002 gives schools a wider remit in the way they deliver the curriculum. Foodlink and the British Nutrition Foundation provide food hygiene training resources for schools and foodlink's annual national food safety week event is starting to focus more on the production of resources to highlight the prevention of cross-contamination and the importance of hand washing.

Compared to the United States however, the UK is still a long way behind in developing a national strategy to train the population in correct practical hand-washing techniques and the contribution it makes to food safety at home as well as in the workplace. The Handwashingforlife Institute aims to reduce the incidence of food-borne illness caused by poor hand hygiene practices. It seeks to provide integrated, objective and practical solutions for the food handlers in industry. The institute plans to make its resources available to food handlers, enforcement agencies, manufacturers and suppliers throughout the world. It has produced a short video that demonstrates the why, when and how of hand washing for food handlers. This wordless video is ideal for getting the hand-washing message across to an audience of mixed language and learning ability. Its effectiveness however, has to be judged on where, when and how the candidates are taught practical hand-washing techniques. Nevertheless, wordless training videos are something that the FSA could consider producing to help the ever-increasing numbers of food handlers who speak little or no English as a second language. Whatever resource is designed for training, any discrimination by ignoring religious and cultural observances must not occur.

LEGISLATION

The Industry Guides to Good Hygiene Practice give little in the way of advice. Guidance omits key aspects to facilitate hand washing. These include the accessibility of wash-hand basins (WHBs), how far a worker has to go to get to them, the frequency of liquid soap dispenser replacements, a regular supply of hot water, and an understanding of proprietors and managers to motivate, evaluate, lead and train staff to wash hands.

If Regulation 4 (3) of the Food Safety (General Food Hygiene) Regulations 1995 is to be properly enforced, enforcement officers must be given advice about effective hand-washing techniques and strategies in FSA documents, for example, in codes of practice. The application and management of hand washing will become a key issue, with the likely requirement, from 2006, for all food businesses to introduce effective food safety management systems based on the principles of Haccp. Applied to hand hygiene this includes risk management, setting targets, implementing best practice, training employees and ensuring management sets an example by providing the resources, time, education, accessible facilities and culture.

LEARNING FROM THE NHS

NHS trusts like the Chelsea and Westminster Hospital and Hammersmith hospitals run hand hygiene awareness weeks, which are targeted at all their staff. Training programmes are also available for medical, nursing, catering and ancillary staff. Infection control teams plan events to make training stimulating and memorable, for instance by producing hand hygiene leaflets for staff, visitors and patients and by using ultra-violet light sensitive powders or gels to demonstrate cross-contamination and the effectiveness of hand washing. They also advertise trained hand hygiene mentors in each ward or department.

GOOD PRACTICE

Micro-organisms that are acquired on the hands fall into two groups: those that live temporarily on the surface of the skin and those that are resident deep in crevices or hair follicles. The former are acquired by touch and may be readily transferred. Soap and water can remove the temporary or transient organisms. However, the resident micro-organisms are not so easily removed by soap and water. Bars of soap may easily become contaminated, so liquid soap or food grade alcohol-based preparations may be considered. Hands should be decontaminated before handling high-risk foods and after raw foods. An implemented and effective food safety management system will help to ensure that hand washing takes place at appropriate stages of the operation.

Finger nails need to be short, rounded and clean. They should not be covered in artificial nails or polish. Rings with ridges or stones will increase bacterial counts. Food handlers should avoid jewellery and watches and sleeves must be rolled up before washing hands. The six-step technique for hand decontamination after wetting hands and applying soap involves rubbing palm to palm, back of both hands, palm to palm with fingers interlaced, back of fingers (interlocked), all parts of both hands, and, finally, both palms with finger tips. The minimum washing time should be 20 seconds. Hands should then be rinsed under running water and dried thoroughly using a paper towel. The taps will need wiping with a dry paper towel, and disinfected at appropriate intervals. The efficacy of hot air dryers is questionable because transient bacteria can survive on wet hands for over three hours.

SOLUTIONS FOR THE FUTURE

Part of the problem lies with the current food hygiene training programmes and the requirement for food business proprietors to ensure that food handlers are supervised and instructed and/or trained in food hygiene matters commensurate with their work activity. With no definitions of supervision, instruction or training given in the legislation or industry guides, owners of businesses and enforcement officers all too often see the achievement of an accredited food hygiene certificate as a means to an end.

The examination bodies, enforcement agencies and trainers need to look towards shorter, more relevant, practically-based courses. Owners of businesses and managers need to be properly trained to enable them to motivate, evaluate, lead and train their own staff in the practical application of food hygiene, including hand-washing techniques. In terms of food safety, accreditation of examinations by the Qualification and Curriculum Authority really does not matter. It's the confidence, consistency, commitment and competence of food handlers that do.

Other examples of possible solutions could include:

• change legislation to require effective hand washing to take place
• install photo sensitive tap, soap dispensers and hot air dryers
• require double soap dispensers to be provided at wash-hand basins
• change perceptions that wearing gloves takes away the need for hand washing
• provide soap dispensers with timed dosimeters to enable managers to assess frequency of hand washing by staff
• ensure hot water is always available
• minimise how far a food handler has to go to get from his/her work station to the wash-hand basin
• redesign hot air dryers so that they heat up quickly - users will then not have to wait very long or give up waiting and dry their hands on their clothing instead
• encourage the use of alcohol gels and wipes that are safe to use in food environments
• appoint trained hand-hygiene mentors within food premises
• develop a national hand-washing strategy and practical training programme and
• produce hand-washing training, materials and information using media that does not rely on the written word to help food handlers with language and/or literacy needs.

A single change in practice will fail. A combined strategy must be implemented involving staff, management, the working environment and the culture within the business. Infection prevention in surgical settings describes hand washing as the "simplest of infection prevention practices, yet the most neglected". The FSA needs to be at the forefront of any national strategy to improve hand hygiene of food handlers (whatever their language, learning ability or culture). Any approach will have to involve partnerships with education, training, healthcare, enforcement agencies and, of course, the hospitality and food industries.

Euan MacAuslan is environmental health training co-ordinator at the Royal Borough of Kensington and Chelsea. E-mail: euan.macauslan@rbkc.gov.uk

The views expressed in this article are those of the author and do not necessarily reflect those of the Royal Borough of Kensington and Chelsea