Food Hygiene Practices Among Preschool Food Handlers in eThekwini,KwaZulu Natal,South Africa: A Cross-Contamination Perspective

Abstract

This study investigated food safety practices at registered Early Childhood Development Centres (ECDs) to determine the relationship between understanding, knowledge, and behaviours of food handlers regarding cross-contamination. Conducted at 61 ECDs in eThekwini, KwaZulu-Natal, it involved 120 food handlers selected through convenience sampling. Data was collected using the WHO’s 5 Keys to Safer Foods self-administered questionnaire. The study revealed that while food handlers in pre-schools showed positive attitudes towards hygiene, significant gaps existed in their knowledge and behaviour. For instance, 69.2% knew a cutting board was safe for raw and cooked foods if clean (P = .003), and only 55% used separate utensils consistently (P < .001). Significant correlations (P = .017) were found between awareness of wiping cloth contamination and the notion that foods should be discarded once they have passed their expiration date, as well as between cleaning surfaces and equipment before using them again for different foods (P = .007). The results highlight the need for tailored food safety interventions for food handlers and indicate the need for environmental health practitioners to conduct such training, focussing on microorganisms, temperature control of foods, and cross-contamination, to improve the safety of food at ECD centres.

Keywords

early childhood development centre food handler cross-contamination food safety food hygiene food hygiene practices

Background

The World Health Organisation’s Foodborne Disease Burden Epidemiological Reference Group published the Global Burden of Foodborne Infections Estimates Report in 2015, highlighting that foodborne infections were a prominent source of morbidity and mortality in humans.¹ This report further emphasised that 40% of this disease burden was in children aged 5 years and younger.¹ The term “foodborne illness” refers to any ailment induced by consuming foods or beverages infected with hazardous microbes or their toxins, such as bacteria, viruses, and fungi.¹ Gastrointestinal disease is the most common symptom of foodborne illness.²

Many children from newborn to 5 years of age spend most of their day at a childcare facility where food is handled, prepared, and served. In South Africa, 38.4% of children under the age of 4 were reported to be attending preschool, as indicated by the General Household Survey.³ These young children are susceptible to illnesses as their immune systems are not fully developed.^4,5

An Early Childhood Development Centre (ECD) is a facility that provides care for children from birth to 6 years of age.⁶ Early childhood care and proper nutrition play a significant role in a child’s development.⁷ Many of these centres provide meals to the children, typically as part of an attractive package for working parents. According to the General Household Survey, 2022, there was a significant increase in registered ECD centres in the country compared to the previous survey conducted in 2015.³ The legal framework governing Early Childhood Development Centres varies nationally and internationally. South African legislation on ECD centres has been progressive over the last decade; however, the focus remains on the quality of educational services, addressing food insecurity, infrastructure, and funding.⁸ In 2021, the Department of Basic Education (DBE) took over governance of these facilities from the Department of Social Development. Municipal Environmental Health Practitioners are responsible for monitoring and evaluating such centres to ensure compliance with the Environmental Health Norms and Standards, 2015 and the National Early Integrated Childhood Development Policy, which falls within the ambit of the South African Department of Social Development.^5,6 The registration of the ECD Centre falls under the municipal bylaws of each province, which provide for Environmental Health requirements, such as the eThekwini Municipality Childcare Facilities Bye law, Notice 200 of 2015.⁹ The DSD Guideline and the National Environmental Health Norms and Standards for Premises and Acceptable Monitoring Standards for Environmental Health Practitioners, Notice 1229 of 2015 refer specifically to the provision of a separate area within the ECD centres for food preparation.^6,10,11 Food premises, including kitchens in ECD Centres, are required to comply with Regulations Governing General Hygiene Requirements for Food Premises, the Transport of Food and Related Matters (R638 of 22 June 2018), which also requires food handlers to be adequately trained.¹² As there are several legislative and compliance authorities which are not cohesively managing the compliance of ECD Centres, gaps in implementation, supervision and accountability can occur.

There is a growing concern in South Africa regarding the lack of food safety practices at ECD centres, which has raised the risk of children becoming ill from contaminated food. In 2019, 164 school children were diagnosed with food-poisoning due to poor food storage practices linked to the school nutrition programme.⁷ In a similar incident, about 30 children fell ill and were hospitalised after consuming food prepared for a grade R graduation at their school situated in the Limpopo province.¹³ In 2023, about 120 school children in the Komani area in the Eastern Cape complained of food poisoning symptoms and about 50 of these children were hospitalised after consuming baked goods from local school vendors.¹⁴ Due to the increase in early childhood development centres and the demand for daycare, as well as the daily meals that are subsequently served at these facilities, it is crucial that good food safety procedures are followed in order to protect the health and well-being of these children. Various studies have linked poor food handling practices to foodborne illnesses, highlighting cross-contamination from cutting boards and utensils, inadequate cooking temperatures, and poor storage of meat as the leading non-compliances.^15
-17 Good food hygiene practices by food handlers, such as hand washing, temperature control, and good storage practices, are essential in preventing foodborne illnesses. Food handler knowledge, behaviour, and practices (KBP) play a crucial role in food safety.¹⁶ Poor food-handling practices have the potential to cause foodborne illnesses and even death. The non-compliance of ECD food handlers regarding good food safety practices places children in the centres at risk of foodborne illnesses and diseases. Children’s systems are vulnerable as they are unable to recognise and combat viruses and parasites, increasing the need to assess food safety practices at ECD centres to reduce the risk of foodborne illnesses.¹⁸ The vulnerability of children’s immune systems in early childhood and the effect on their educational development was highlighted in a study conducted in Bangladesh.¹⁹

The sudden increase in the number of ECD centres in South Africa, both in formal and informal areas, raises concerns about food safety measures. The knowledge, behaviour, and practices of food handlers play an integral part in ensuring that the food prepared is safe to consume and does not pose a risk to public health.²⁰ Food prepared for mass events such as conferences, meetings, schools, creches, and restaurants caters to many people daily. Thus, the risk of cross-contamination arising from poor food-handling practices, inadequate personal hygiene, improper food temperatures and storage practices, or a lack of knowledge thereof is high. Globally, numerous studies have assessed the knowledge, practices, and attitudes (KPA) of food handlers. Studies conducted in Ghana assessing the KPA of food handlers at institutional facilities concluded that although food handlers possessed satisfactory knowledge of basic handwashing, 76.2% of the 235 food handlers were unaware of food pathogens such as Salmonella spp.¹⁶ A similar study conducted on food-handler knowledge at creches highlighted that many food handlers lacked knowledge on cooking temperatures of meat and that food handlers who had longer years of work experience were more knowledgeable in sanitary aspects of a food preparation area in comparison to food handlers that were new in the food service environment.²¹ Knowledge and practices of food handlers are therefore crucial during food preparation.

Although national legislation mandates adequate training for food handlers, it is posited that food handlers at ECD centres may have limited knowledge of safe food handling practices—particularly concerning cross-contamination—given the recent reports of foodborne illnesses among young children in South Africa.^7,13,14

This research aims to identify any knowledge gaps by investigating and determining the level of food safety knowledge and practices among food handlers in relation to their understanding of cross-contamination at registered centres within the eThekwini Region. The objective for this research was to determine the relationship between demographic data, the knowledge and behaviour of food handlers at the ECD centres, and their knowledge of the spread of microorganisms through dishcloths.²² As dishcloths have been found to be inappropriate to use to clean kitchen surfaces, any knowledge food handlers may have regarding dishcloths, and the spread of microorganisms was examined.²² Results of this research will enable the formulation of targeted education for food handlers, specifically addressing the spread of microorganisms, to provide the best possible outcomes and assist in addressing the burden of foodborne illnesses in children.¹⁵

Methods

Study Area: The study was conducted in the eThekwini Region, formerly known as Durban, of KwaZulu-Natal Province (KZN), South Africa (Figure 1). The KZN province is divided into 1 Metropolitan Municipality (eThekwini) and 10 district municipalities, which are further subdivided into 43 local municipalities. eThekwini can be described as the economic hub of the province and is noted as one of the most important industrial regions. The study focussed on the registered early childhood centres within the Spatial Regions of eThekwini. That is, North, Central, South, and Outer West. The region has a diverse socioeconomic landscape, including urban, peri-urban, and informal settlements. While certain areas of the municipality are well-developed, others face infrastructure issues, including inadequate access to basic services such as sanitation, clean water, and electricity. This gap creates significant public health and service delivery issues, particularly in sectors such as early childhood development, where access to clean water and electricity is crucial. According to the 2022 census of the area, the region has a population of 4.2 million, with females accounting for 52.4% and males for 47.6%. The Black African is the largest ethnic group, followed by Indians (23.7%), Whites (15.3%), and Coloureds (8.6%).

Study Design: This study employed a quantitative, cross-sectional design. Convenience sampling was utilised as the sampling method, as it allowed for the selection of participants based on their availability and willingness to participate. The study population consisted of 160 registered ECD centres, as listed by the eThekwini Municipality Environmental Health Monitoring and Evaluation division. The list only included ECDs that were in possession of a certificate of acceptability granted to the premises by an Environmental Health Practitioner in accordance with Regulations Governing General Hygiene Requirements for Food Premises, the Transport of Food and Related Matters, R638 of 22 June 2018.¹² This ensured that all ECDs in the sample had similar food preparation facilities, including running water, wash basins, food preparation surfaces, sufficient storage areas, and refrigeration facilities. A sample size was calculated by using a 97% confidence interval and a 5% margin of error. Epi Info version 7.2.6 was utilised to estimate a sample size of 119. ECD centres were contacted by telephone to explain the nature of the study and to determine potential participation. Challenges were encountered with the municipal database, as some ECD centres were no longer operational, and several contact numbers and physical addresses were incorrect. In addition, the database was not comprehensive, representing only a subset of areas within the municipality. Consequently, convenience sampling was employed, enabling the selection of ECD centres and participants based on their availability and willingness to participate. Each ECD centre was visited by the researcher to provide information about the study and invite participation from food handlers. Of the 160 ECD centres initially identified, 61 consented to participate. A total of 120 food handlers agreed to participate in the study, while 2 declined to participate. The centres were geographically spread throughout the entire sample region, and once a total of 120 participants was reached, no additional centres were enrolled in the study. Participant inclusion in the study was based on their willingness to participate and being over 18 years of age, as required for obtaining informed consent.

Data Collection: The Environmental Health ECD database, obtained from the eThekwini Municipality (local authority), was used to gather information about the registered ECD centres in the region. Information obtained included the centre’s name, address, and contact numbers. Data collection commenced on June 24, 2024, and continued until July 10, 2024. The researcher and research assistant travelled to the sample sites to deliver printed information letters, consent forms, and questionnaires after making telephonic enquiries prior to the visit. An information letter was provided to all prospective participants, detailing the study’s purpose, goals, risks, and benefits. It also outlined the confidentiality of participants, reiterating that their information would be kept confidential and that their right to privacy would be respected. They were assured that they could withdraw from the study at any time and were under no obligation to participate. Their non-participation would not affect their working conditions or relationship with their employer in any way. A signed informed consent form was obtained from each prospective participant prior to their participation. Questionnaires were self-administered by the food handlers to assess their practices and knowledge of food safety.

Research Instrument: The 5 Keys of Food Safety questionnaire developed by the World Health Organisation (WHO) was used to determine the level of food safety practices at the ECD centres.²³ This validated data-collection instrument was used to maintain reliability and internal consistency. The questionnaire had been tested on a small pilot study group, and it was found that the questions were easy to read and understand. No adjustments were made to the questionnaire’s format before applying it to the main sample group. The questionnaire consisted of a biographical section that collected data on gender, educational qualifications, and years of experience. The results of this section were used to indicate representation within the sample population. Information bias was mitigated by allowing each participant to complete their own questionnaire independently, without assistance from a coworker or the researcher. The questionnaire consisted of 4 pages, written in English, which is considered the primary language for discourse in South Africa, and is used in government and media communications. A recently qualified Environmental Health Practitioner with community service experience served as a research assistant and interpreter during data collection. She was fluent in isiZulu and provided clarification of terminology in the local language when needed. Although the pilot study indicated that full translation of the questionnaire was unnecessary, her language support remained available to participants throughout the main study. There were 5 sections, each focussing on a key aspect of food safety. Within each section, there were both closed-ended and Likert-scale type questions, typically around 4 to 6 questions per section, which took less than 15 minutes to complete.

Statistical Analysis: The IBM Statistical Package for the Social Sciences (SPSS) version 29.0 was used for statistical analysis. Types of analysis included descriptive and inferential. Frequencies were calculated for all categorical variables. The Pearson’s Two-sided Chi-Square analysis was used to determine if there was a significant relationship between demographic factors (eg, education level, gender) and food safety practices (P < .05), as the study aimed primarily to explore associations or describe relationships between categorical variables, rather than to predict outcomes or control for confounding. The relationships between continuous variables such as work experience and compliance with safe food handling practices were assessed. Given the descriptive purpose of this study and the categorical nature of the variables, chi-square analyses provided a clear and interpretable method for examining these associations.

Figure 1.

Map indicating the location of eThekwini in South Africa.

The variable “Wiping cloths can spread microorganisms” was analysed in relation to other food hygiene practices and behavioural variables to assess the presence of any significant associations. This variable was selected as an indicator of food handlers’ understanding of bacterial transmission from contaminated to clean surfaces or from cloths to hands, thereby reflecting their awareness of how unclean cloths can contribute to cross-contamination in kitchen environments.^22,24

Ethical Aspects

Every participant was informed of the study’s purpose, objectives, goals, risks, benefits, confidentiality, and the voluntary nature of their participation through a written document, specifically an information letter. Once the participants read and understood the information letter and all their queries and concerns were addressed, they provided written consent by signing the informed consent form provided. This study was approved by the University of Johannesburg, Faculty of Health Science Research Ethics Committee under clearance number REC-2594-2024 and KwaZulu-Natal Department of Education (Ref.:2/4/8/227).

Results

A total of 160 Early Childhood Development (ECD) food handlers participated in the study. Participant characteristics and food-safety knowledge, attitudes, and practices are presented according to the WHO 5 Keys to Safer Food framework. The results are presented based on the participants’ response to the statement in the questionnaire, “Wiping cloths can spread microorganisms,” in relation to other questions and statements to report on the comparisons and relationships between them.

In Table 1, the cross-tabulation results explored the transfer of microorganisms by wiping cloths (cross-contamination) based on demographic variables, including gender, age, years of work in ECD centres, educational attainment, and history of training. Although this association was not statistically significant (P = .214), 80.8% of females, 7.5% of males, and 11.7% of those who preferred not to reveal their gender believed that wiping cloths could spread microbes. Participants in the 45 to 55 age range had the highest tendency towards this opinion, at 34.2%, while those aged 18 to 24 had the lowest tendency, at 6.7%. No relationship of significance was observed (P = .971).

Table 1.

Description of Demographic Characteristics According to Knowledge of Cross-Contamination (Wiping Cloths Spread Microorganisms).

Question	Response	P-value
Gender		.214
Male	9 (7.5%)
Female	97 (80.8%)
Prefer not to say	14 (11.7%)
Age		.971
18-24 y	8 (6.7%)
25-34 y	19 (15.8%)
35-44 y	36 (30%)
45-55 y	41 (34.2%)
55 y and older	16 (13.3%)
No. years employed at ECD		.516
Less than 6 mo	6 (5.0%)
6 mo to 1 y	14 (11.7%)
1-2 y	10 (8.3%)
2-5 y	29 (24.2%)
Longer than 5 y	61 (50.8%)
Education level		.166
No formal education	6 (5.0%)
Primary school	8 (6.7%)
Secondary school	66 (55%)
Tertiary school	33 (27.5%)
Other	7 (5.8%)
Training level		.219
Yes, within the last year	9 (7.5%)
Yes, more than a year ago	35 (29.2%)
Never undergone training	76 (63.3%)

The understanding of microbial spread was also assessed by the years of work experience at ECD centres, finding that those with more than 5 years’ experience were the most aware (50.8%; P = .516). The educational background revealed that 55% (P = .166). Individuals with secondary education are most likely to be aware of microbial risks associated with wiping cloths. There were 63% of participants who had never undergone food safety training; these participants understood the microbial risks associated with wiping cloths at 63.3% (P = .219). The Chi-square analysis revealed varying levels of understanding regarding the potential for wiping cloths to spread microorganisms across different categories, including gender, age, education, work experience, and food safety training; however, none of these associations reached statistical significance (all P > .05). These findings suggest that neither demographic characteristics nor prior training significantly impacted participants’ knowledge of cross-contamination risks in ECD settings.

In Table 2, the cross-tabulation results investigated the statement that wiping cloths spread microorganisms in relation to Key 2 questions, which focussed on assessing food handlers’ knowledge of food safety practices. This analysis focussed on food handlers’ awareness of crucial aspects of safe food handling, including the use of cutting boards for raw and cooked foods, proper storage of raw and cooked foods, and other critical practices. Correct responses were defined according to the WHO 5 Keys recommendations. For negatively phrased items (eg, “The same cutting board can be used for raw and cooked foods” and “Cooked foods do not need to be thoroughly reheated”), the response “False” was treated as the correct answer to reflect appropriate food-safety practices. The table displays both significant and non-significant relationships between various food safety practices and knowledge among ECD personnel. Approximately 69.2% of participants incorrectly agreed that the same cutting board can be used for both raw and cooked dishes if it appears clean, indicating a misunderstanding of the risks associated with cross-contamination. This practice was found to have a significant association (P = .003) with the knowledge that washcloths can spread microorganisms. Further research revealed a significant correlation between the necessity of storing cooked and raw foods separately and the percentage of respondents who agreed with this practice (75.8%; P = .001). Three-quarters of respondents (75.8%; P = .225) agreed that prepared foods do not require careful reheating.

Table 2.

Description of Food Handling Knowledge According to Knowledge of Cross-Contamination (Wiping Cloths Spread Microorganisms).

Question	True (Responses)	False (Responses)	P-value
Key 2aThe same cutting board can be used for raw and cooked foods, provided it looks clean	83 (69.2%)	37 (30.8%)^*	.003
Key 2bRaw food needs to be stored separately from cooked food	91 (75.8%)	29 (24.2%)	.001
Key 3aCooked foods do not need to be thoroughly reheated	91 (75.8%)	29 (24.2%)^*	.225
Key 3bProper cooking includes meat cooked to 40°C	100 (83.3%)	20 (16.7%)^*	.306
Key 4a * Cooked meat can be left at room temperature overnight to cool before refrigerating	90 (75.0%)	30 (25%)	.520
Key 4bCooked food should be kept very hot before serving	81 (67.5%)	39 (32.5%)	.069
Key 4c * Refrigerating food only slows bacterial growth	83 (69.2%)	37 (30.8%)	.483
Key 5aSafe water can be identified by the way it looks	90 (75.0%)	30 (25%)	.018
Key 5b * Wash fruit and vegetables	116 (96.7%)	4 (3.3%)	.79

*Correct responses aligned with WHO 5 Keys²³ guidance, and for negatively worded statements, “False” indicated the correct safe-food practice.

Additionally, a high number (83.3%) of respondents believed that properly cooked meat should be cooked to 40°C; however, this knowledge was not substantially correlated with a broader understanding of cross-contamination (P = .306). Although 75% of people agreed that cooked meat could be left out overnight at room temperature, there was no correlation between this practice and cross-contamination (P = .520). Food handler behaviour regarding maintaining cooked food at a high temperature before serving showed marginal significance (67.5%; P = .069), suggesting a partial understanding of this precautionary measure.

There was no significant correlation (P = .483) between cross-contamination and the notion that refrigerating food merely delays bacterial development. On the other hand, 75% of respondents agreed that the appearance of safe water may be a determining factor (P = .018). Lastly, almost all participants (96.7%; P = .793) agreed that washing fruits and vegetables is a good idea. Questions related to refrigerated procedures, cooking temperatures, and meal reheating were not significantly associated with the concept that microbes are passed by the wiping cloths.

Once again using the statement “Wiping cloths can spread microorganisms,” Table 3 focussed on the attitude of food handlers, which indicated significant associations in Key 2. Correct responses were aligned with the WHO 5 Keys²³ guidance. For negatively phrased items, the “False” option represented the correct attitude in accordance with safe food-handling principles. A total of 94.2% of respondents recognised that frequent handwashing during food preparation is worthwhile, despite the extra time required (P = .066), while 91.7% understood the importance of discarding expired food (P = .747). Almost all participants (96.7%) agreed that cleaning kitchen surfaces reduces the risk of illness (P = .265). With a substantial P-value of <.001, 72.5% of participants who correctly understood the concept of cross-contamination recognised separating raw and cooked food as an essential method to prevent disease. Furthermore, 55.0% of respondents understood that using different knives and cutting boards for raw and cooked items was a safe food handling practice (P = .001), and 56.7% agreed that using a meat thermometer was useful for ensuring thorough cooking (P = .008). Most participants (81.7%) agreed that soups and stews should always be boiled to ensure safety (P = .061). Additionally, 75.0% of respondents reported that thawing food in a cool environment was safer (P = .017). 48.3% of participants thought it was unsafe to keep prepared food out of the refrigerator for more than 2 hours (P = .081), whereas 93.3% said examining food for freshness was beneficial (P = .706).

Table 3.

Description of Food Safety Practices According to Knowledge of Cross-Contamination (Wiping Cloths Spread Microorganisms).

Key	True (Responses)	False (Responses)	P-value
Key 1aFrequent handwashing during food preparation is worth the extra time	113 (94.2%)	7 (5.8%)	.066
Key 1bKeeping kitchen surfaces clean reduces the risk of illness	116 (96.7%)	4 (3.3%)	.265
Key 2aKeeping raw and cooked food separate helps to prevent illness	87 (72.5%)	33 (27.5%)	<.001
Key 2bUsing different knives and cutting boards for raw and cooked foods	66 (55.0%)	54 (45.0%)	.001
Key 3aMeat thermometers are useful for ensuring food is cooked thoroughly	68 (56.7%)	52 (43.3%)	.008
Key 3bSoups and stews should always be boiled to ensure safety	98 (81.7%)	22 (18.3%)	.061
Key 4aThawing food in a cool place is safer	90 (75.0%)	30 (25.0)^*	.017
Key 4bIt is unsafe to leave cooked food out of the refrigerator for more than 2 h	58 (48.3%)	62 (51.7%)	.081
Key 5aInspecting food for freshness and wholesomeness is valuable	112 (93.3%)	8 (6.7%)	.706
Key 5bI think it is important to throw away food that have reached its expiry date.	110 (91.7%)	10 (8.3%)	.747

*Correct responses aligned with WHO 5 Keys guidance,²³ and for negatively worded statements, “False” indicated the correct safe-food practice.

In Table 4, the focus was on the behaviour and practices of food handlers with the statement, “Wiping cloths can spread microorganisms.” Correct behavioural responses were guided by the WHO 5 Keys practices.²³ For negatively phrased items, the “False” response reflected the appropriate food-safety behaviour. There were significant correlations, with P-values below the accepted .05 threshold, between the idea that bacteria are transmitted by wiping cloths and certain food safety practices. Using different cutting boards and utensils for raw and cooked food preparation (correct practice) was associated with a significant correlation (P < .001) between knowledge of wiping cloth contamination and practices. Cleaning surfaces and equipment before reusing them for different foods, which is a correct food-safety practice, also showed a significant correlation (P = .007). Additionally, a significant correlation (P = .017) was found between awareness of wiping cloth contamination and the notion that food should be thrown out once it has passed its expiration date. In Key 3, “Cook thoroughly,” 31.7% of participants frequently ensure that meats are properly cooked by checking for clear juices or using a thermometer (P = .020). Regarding reheating methods, 34.2% of respondents often reheated prepared food until it was piping hot throughout (P = .004). In Key 4, awareness of wiping cloth contamination was substantially correlated with the practice of storing leftovers in a cool location within 2 hours of cooking (P = .005). Specifically, 35.8% of participants reported occasionally engaging in this practice, and 33.3% reported frequently doing so. In Key 5, “I think it is important to throw away foods that have reached their expiry date,” 53.3% of participants frequently checked and discarded food past its expiration date (P = .009). There were also some non-significant correlations, such as handwashing compliance (68.3%; P = .252) and the frequency of cleaning surfaces and equipment before reuse (58.3%; P = .007).

Table 4.

Description of Food Handling Behaviour According to Knowledge of Cross-Contamination (Wiping Cloths Spread Microorganisms).

Key	Never	Rarely	Sometimes	Always*	P-value
Key 1a+I wash my hands before and during food preparation.	1 (0.8%)	5 (4.2%)	32 (26.7%)	82 (68.3%)	.252
Key 1b+I clean surfaces and equipment before re-using on other food.	3 (2.5%)	-	47 (39.2%)	70 (58.3%)	.007
Key 2a*I use separate utensils and cutting boards for raw and cooked food.	9 (7.5%)	14 (11.7%)	42 (35.0%)	5 (45.8%)	<.001
Key 2bI separate raw and cooked food during storage.	9 (7.5%)	25 (20.8%)	44 (36.7%)	42 (35.0%)	.017
Key 3aI check that meats are cooked thoroughly by ensuring that the juices are clear or using a thermometer.	32 (26.7%)	22 (18.3%)	28 (23.3%)	38 (31.7%)	.020
Key 3bI reheat cooked food until it is piping hot throughout.	7 (5.8%)	18 (15.0%)	54 (45.0%)	41 (34.2%)	.004
Key 4aI thaw frozen food in the refrigerator or other cool place.	20 (16.7%)	17 (14.2%)	30 (25.0%)	53 (44.2%)	<.001
Key 4bAfter cooking a meal, I store leftovers in a cool place within 2 h.	12 (10.0%)	25 (20.8%)	43 (35.8%)	40 (33.3%)	.005
Key 5aI check and throw away food beyond its expiry date.	-	10 (8.3%)	46 (38.3%)	64 (53.3%)	.009
Key 5bI think it is important to throw away foods that have reached their expiry date.	-	5 (4.2%)	51 (42.5%)	64 (53.3%)	.017

“Often” and “Always” have been combined to reflect the correct safe-food behaviour.

Results Summary: According to the WHO 5 Keys²³ Layout

Key 1 – Keep Clean

In Table 1, the cross-tabulation results explored the transfer of microorganisms by wiping cloths (cross-contamination) based on demographic variables such as gender, age, years of work in ECD centres, educational attainment, and history of training. Although the association was not statistically significant (P = .214), most respondents who believed wiping cloths can spread microbes were female (80.8%), compared to 7.5% of males and 11.7% who did not disclose their gender. Participants in the 45 to 55 age range had the highest tendency towards this opinion at 34.2%, while participants aged 18 to 24 had the lowest tendency at 6.7%.

In Table 3, attitudes reflected strong agreement for handwashing (94.2%; P = .066) and cleaning surfaces (96.7%; P = .265). 72.5% recognised separation of raw and cooked food prevents illness (P < .001). 55% recognised the importance of separate knives or cutting boards (P = .001).

In Table 4, practices showed significant associations: using separate boards (P < .001), cleaning surfaces before reuse (P = .007), storing leftovers correctly (P = .005), and discarding expired food (P = .009). Handwashing behaviour showed no significant link (P = .252).

Key 2 – Separate Raw and Cooked

In Table 2, a cross-tabulation explored the relationship between wiping-cloth contamination knowledge and safe-handling practices. 69.2% incorrectly believed the same cutting board could be used for raw and cooked dishes (P = .003). 75.8% correctly recognised that raw and cooked foods must be stored separately (P = .001). 75.8% incorrectly reported that prepared foods do not need careful reheating.

Key 3 – Cook Thoroughly

In Table 2, a cross-tabulation was conducted to explore the relationship between wiping-cloth contamination knowledge and safe-handling practices. 69.2% incorrectly believed the same cutting board could be used for raw and cooked dishes (P = .003). 75.8% correctly recognised that raw and cooked foods must be stored separately (P = .001). 75.8% incorrectly reported that prepared foods do not need careful reheating.

Additionally, 83.3% incorrectly believed proper cooking means meat cooked to 40°C. 75% incorrectly agreed that cooked meat could be left at room temperature overnight. Maintaining cooked food at a hot temperature before serving showed marginal significance (67.5%; P = .069).

Key 4 – Keep Food at Safe Temperatures

Respondents (75%) incorrectly agreed that cooked meat could be left at room temperature overnight, while maintaining cooked food hot before serving showed marginal significance (67.5%; P = .069).

Key 5 – Use Safe Water and Raw Materials

Discussion

Dishcloths are not always effective in cleaning and disinfecting kitchen surfaces, as they have been found to contain faecal coliforms and foodborne pathogens.²² Research conducted in the United Kingdom and Europe shows that 29% of people use cloths to wipe up juices and do not change the cloth afterwards, and that in the United Kingdom, there is a discrepancy between their high awareness of hygiene practices and their cloth practices.²⁴ The correlation results aimed to explore the “wiping cloths spread microorganism” statement and its relation to the knowledge and behaviour of food safety. The findings revealed no correlation between food safety practices and gender, age, educational level, or years of practice, particularly within ECD centres. This is contrary to other studies, which found that education levels and experience impact food safety behaviour.^25,26 This is also demonstrated in a study conducted in a school in Brazil, where, although food handlers possessed food-safety knowledge, this did not consistently translate into safe practices, aligning with our finding that awareness of microbial risks (eg, wiping cloths and cross-contamination).²⁷ The findings on gender differences, as shown in Table 1, revealed that 80.8% of female respondents knew that wiping cloths can transfer microbes, compared to 7.5% of male respondents. Although this difference was not statistically significant (P = .214), it is notable. Age, education, and work experience did not affect whether participants knew that wiping cloths can spread germs. However, some still misunderstand the risks of cross-contamination. For example, those who believed the same cutting board can be used for raw and cooked food were less likely to understand the risk from wiping cloths (P = .003). This corresponds with a study conducted, which highlighted concerns about cross-contamination due to a lack of knowledge about using separate cutting boards for raw and cooked foods.²⁸ Similarly, an Italian study found that despite reasonable awareness of hygienic food handling principles, gaps persisted in applying cross-contamination prevention measures, illustrating a recurring knowledge and behaviour disconnect even in regulated European settings.²⁹ Furthermore, 75.8% of respondents stated that raw and cooked foods should be stored separately, indicating a significant relationship (P = .001) once again between the “wiping cloth” cohort and the others. These findings show that, while demographics have no substantial impact on knowledge of the concept that wiping cloths spreads microorganisms, those food handlers who understood this concept were also able to practice many other safe food behaviours, such as separating raw and cooked foods and using clean cutting boards.³⁰ This also aligns with evidence from a study in Ghana where institutional food-handlers demonstrated high awareness of contamination risks but still exhibited inconsistent hygiene practices, indicating behaviour challenges beyond demographic influence.¹⁶ There are specific gaps in comprehending critical safety precautions. These findings emphasise the significance of specific training in correcting misconceptions, particularly those about cross-contamination and using separate utensils for raw and cooked foods. This finding correlates with the study conducted in Bangladesh, which found no significant correlations between demographic characteristics and food safety knowledge.³¹ The findings, however, are in contrast with the study conducted in Pakistan, which showed that demographic factors such as level of education, professional category and job experience were significantly associated with food handler knowledge, practices and attitudes.³²

The findings suggest good awareness of the risks associated with wiping cloths and the transfer of microorganisms across all demographic groups, with no strong statistical associations indicating the need for targeted education and training to enhance food safety awareness in specific groups. This finding was similarly aligned with the study’s findings, which emphasised that food handlers had a good understanding of food safety practices and identified a significant relationship between the knowledge and attitudes of food handlers.³³ Similarly, the study conducted in Durban on reusing tea towels indicated that food handlers were well aware of the risks of using tea towels but did not understand that these cloths must be placed in a sanitising solution.³⁴

The significant association suggests that individuals who understand the risks associated with wiping cloths also recognise the importance of discarding expired foods (P = .017). This highlights a broader understanding of how expired foods can harbour harmful microorganisms, which aligns with other safe food handling practices. Similar studies were found in a study in Lesotho assessing knowledge, behaviour and self-reported behaviour of street food vendors.³⁵

In terms of the statement “Thawing Frozen Food in the Refrigerator” (P < .001), food safety knowledge also had a substantial impact on behaviour when it came to thawing food in a refrigerator or cool place. Although 44.2% of respondents practised this action, it was not associated with demographic criteria, such as gender or years of experience. This suggests that awareness of safe food handling techniques is a stronger predictor of behaviour if the concept of cross-contamination is understood. A significant association exists between participants who apply proper thawing methods and those who prevent the spread of microorganisms (P < .001). This highly significant association indicates a strong understanding among participants that proper thawing methods prevent bacterial growth.^36,37 This aligns with the study conducted in Ethiopia, where higher food safety knowledge and attitudes significantly predicted correct handling behaviours, supporting our finding that conceptual understanding is a key behavioural driver irrespective of demographic characteristics.³⁸

Similarly, ensuring that meat is cooked thoroughly, either by checking that the juices run clear or by using a thermometer, was practised by only 31.7% (P = .020) of respondents. While this behaviour was statistically significant in relation to food safety knowledge, demographic data did not significantly predict this behaviour. These findings are in contrast with the study findings, which found a significant association between the age of students and food-safety practices, with the age category 18 to 24 years more likely to practice better food safety.³⁹ These findings, however, are also in contrast to the study which found that food handlers lacked significant food safety knowledge and understanding as well as to the study which found that elements like gender and experience did not significantly affect food-safety practices.^40,41

Limitations

This study was limited to ECD centres within the eThekwini municipality in KwaZulu-Natal and employed convenience sampling, which restricts the generalisability of the findings to other ECD centres or food handlers in different regions. This sampling approach may introduce selection bias and limit external validity. Participant availability was also constrained, as data collection coincided with the mid-year school holidays. The possibility of volunteer bias must be acknowledged, as individuals who choose to participate may differ from non-participants in their awareness, interest, or commitment to food safety practices. This could limit the representativeness of the sample and the extent to which the findings reflect the broader population of food handlers in eThekwini. Although the questionnaire, adapted from WHO, included both closed-ended and Likert-scale questions to improve consistency, it does not account for acquiescence bias or social desirability bias. Allowing participants to complete the forms anonymously and confidentially may have partially mitigated this limitation. Some ECD centres demonstrated resistance or lack of cooperation, potentially due to stigma or apprehension associated with visits from Environmental Health Practitioners. These challenges highlight the need for tailored and refresher training programmes for food handlers in ECD centres to address gaps in food safety knowledge and practices.

Conclusion

One of the key public health concerns identified in this study is the potential for foodborne illnesses arising from gaps in critical food safety knowledge and practices. The findings indicate that food handlers who demonstrate an understanding of cross-contamination exhibit significantly better food hygiene practices than those who do not, underscoring the importance of targeted educational interventions focussing on this aspect. Given South Africa’s resource constraints and the shortage of Environmental Health Practitioners (EHPs), these professionals—who possess specialised knowledge of food safety and hold a strategic role within the ECD sector—are well positioned to deliver such training. The results of this study can therefore inform the development of effective, targeted training programmes by EHPs, with a particular emphasis on microorganisms and cross-contamination, to enhance food safety within ECD centres.

Footnotes

Acknowledgements

University of Johannesburg Statistical Consultation Services.

Author Note

This work was completed as part of a Master’s mini dissertation titled, “Determining the Levels of Food Safety Practices at Registered Early Childhood Development Centres within the eThekwini communities.”

ORCID iDs

Samantha Lange

Renay H. Van Wyk

Ethical Considerations

Ethical approval received from the University of Johannesburg, Faculty of Health Sciences. Ethical Clearance Number: REC 2594 2024.

Author Contributions

All authors discussed the results and contributed to the preparation of the final manuscript. The authors read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.*

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