Content uploaded by Refat Alkurd
Author content
All content in this area was uploaded by Refat Alkurd on Jan 19, 2023
Content may be subject to copyright.
Content uploaded by Refat Alkurd
Author content
All content in this area was uploaded by Refat Alkurd on Aug 09, 2022
Content may be subject to copyright.
Content uploaded by Nour Amin Elsahoryi
Author content
All content in this area was uploaded by Nour Amin Elsahoryi on May 13, 2021
Content may be subject to copyright.
Food allergy knowledge, attitudes
and practices (KAP) among
restaurant’s staff in Jordan:
a cross-sectional study
Nour Amin Elsahoryi, Refat Alkurd and Leena Ahmad
Department of Nutrition, Faculty of Pharmacy and Medical Sciences,
University of Petra, Amman, Jordan
Amin N. Olimat
Department of Clinical Nutrition and Dietetics, Faculty of Applied Medical Sciences,
The Hashemite University, Zarqa, Jordan
Fwzieh Hammad
Jordan University of Science and Technology, Irbid, Jordan, and
Richard Holley
University of Manitoba, Winnipeg, Canada
Abstract
Purpose –People with food allergies rely to a great extent on restaurant staff to have a safe meal. The purpose
of this paper is to acquire novel data to evaluate knowledge, attitudes and practices of food allergy among the
restaurant’s staff and factors that could be associated with these domains.
Design/methodology/approach –A cross-sectional study involving 306 restaurant staff in Amman City,
Jordan was conducted using a validated self-reported questionnaire. Logistic regression analysis was
performed to identify factors independently associated with knowledge, attitude and practices (KAP).
Findings –The results showed that most restaurant staff had moderate to excellent knowledge, positive
attitudes, low to moderate risk practices regarding food allergy. Knowledge level was significantly associated
with the staff’s age, position, education level and restaurant class. Further, attitude level was significantly
associated with staff age, experience, gender, education level, restaurant class and whether the restaurant held
food safety certificates. Similarly, staff behavioral practices were significantly associated with staff position,
restaurant class and the presence of valid food safety certificates.
Practical implications –This study suggests that more training for the staff in restaurants would be
associated with a lower risk of providing unsafe meals.
Originality/value –This study demonstrated the need for the pre-employment theoretical and practical
tests for restaurants’staff to determine their knowledge level and provide them mandatory developing
training programs to support and facilitate food allergy risk management and to develop food allergy
policies.
Keywords Food allergy, Knowledge, Attitude and practice, Restaurant staff
Paper type Research paper
Food allergy
KAP among
restaurant’s
staff
The authors gratefully acknowledge the support received from Scientific Research Board of Petra
University, Amman, Jordan
Financial support: The Funding was provided by the Dean of Scientific Research and Graduate
Studies, University of Petra, Amman, Jordan.
Author contributions: Nour Amin Elsahoryi designed the study, collected, analyzed, interpreted data
and wrote the manuscript. Refat Alkurd contributed in designing the study, data collecting and writing
the manuscript. Leena Ahmad contributed in writing the manuscript. Fwzieh Hammad contributed in
designing the study and data analysis. Amin N. Olimat and Richard Holley revised the manuscript. All
authors read and approved the final manuscript.
Conflicts of interest: There are no conflicts of interest.
The current issue and full text archive of this journal is available on Emerald Insight at:
https://www.emerald.com/insight/0007-070X.htm
Received 18 June 2020
Revised 14 August 2020
3 October 2020
Accepted 18 October 2020
British Food Journal
© Emerald Publishing Limited
0007-070X
DOI 10.1108/BFJ-06-2020-0522
1. Introduction
1.1 Food allergies
Food allergies (FA) are immune-mediated adverse reactions to food proteins that can range
from immediate, potentially life-threatening reactions to chronic disorders (Iweala et al., 2018;
Licari et al., 2019). Food allergies can occur among all susceptible populations, not just with
people who have immunity-related risks. An immune response to food can be
immunoglobulin E (IgE)-mediated (Ferraro et al., 2019;Lessa et al., 2016;Loerbroks et al.,
2019;Stoneman, 2018;Wang and Sampson, 2009). A recent study reported that the
prevalence of food allergy is a growing concern globally; IgE-mediated food allergies are the
most common, affecting up to 10% of children worldwide (Licari et al., 2019). Similarly, it was
reported by the World Allergy Organization (WAO) that 240m people (3%) suffer from food
allergy worldwide (Ferraro et al., 2019). The most common food allergens causing reactions in
children and adults are milk, eggs, wheat, soy, peanuts, tree nuts, fish and shellfish (Ferraro
et al., 2019). The symptoms of food allergic reactions vary in type and severity among
individuals and even in the same individual over time (Ferraro et al., 2019). Symptoms can
affect all body organs; skin, gastrointestinal tract and respiratory system, and they may
extend to anaphylaxis (Ferraro et al., 2019;Lessa, Lozano et al., 2016;Loerbroks et al., 2019;
Stoneman 2018;Wang and Sampson, 2009). Allergen exposure can lead to mucous membrane
symptoms such as red, watery eyes; skin symptoms such as itchiness; gastrointestinal
symptoms, such as nausea and vomiting; upper respiratory symptoms, such as nasal
congestion; lower respiratory symptoms, such as difficulty breathing; cardiovascular
symptoms, such as hypertension and finally, mental or emotional symptoms, such as a sense
of “impending doom,”(CDC, 2013). Food allergy therapies are controversial; to date, there is
no FDA-approved therapy (Iweala et al., 2018). Currently approved strategies simply state
that avoidance of the food allergen is the only way to manage FA. However, food avoidance
can be very difficult since many common food allergens are ubiquitous in the diet; therefore,
using medication such as epinephrine in emergency cases is indicated for relief of symptoms
(Licari et al., 2019).
Alternatively, increasing knowledge of FA among patients and their support groups
regarding cross-contamination, food label monitoring and prompt recognition and treatment
of allergic reactions is a cornerstone of FA management (Licari et al., 2019).
In everyday life, it is very challenging to avoid all allergic foods, particularly when
patients have limited ability to exert dietary control, for example when eating outside of the
home, such as in a restaurant. Under such circumstances, allergen exposure is often caused
by inadvertent cross-contact (-contamination) during food preparation or the inclusion of
ingredients that might not be reasonably expected by consumers. Even when consumers
appropriately communicate their dietary needs to restaurant staff, the actual provision of
suitable foods remains contingent upon the knowledge, attitudes and subsequent practices of
the staff. Accordingly, food allergy awareness among restaurant staff have attracted
increasing interest; particularly as prior research has suggested profound knowledge gaps
can exist (Loerbroks et al., 2019). Awareness among public health authorities regarding the
issue of food allergies has increased and has highlighted the importance of FA knowledge
and practices among food handlers and restaurant staff. Raising the FA awareness among
food handlers and food suppliers might reduce the prevalence of food allergy consequences
and improve the compliance with safety requirements. This is especially important for
children, adolescents and the elderly, who often cannot themselves recognize potentially
risk foods and are dependent solely on food service workers or care givers to reduce risk
(Din et al., 2018).
Many studies have worked on improving FA knowledge and practices among restaurant
staff regarding the nutritional, clinical and food hygiene aspects as well as safe practices from
farm to fork to reduce the occurrence of food allergies (Ajala et al., 2010;Bailey et al., 2011;
BFJ
Bunney et al., 2017;Karajeh et al., 2005;Lef
evre et al., 2018;Lessa et al., 2016;Loerbroks et al.,
2019;Stoneman 2018). Most studies showed that the participants had moderate FA
knowledge (Ajala et al., 2010;Loerbroks et al., 2019). In Jordan, research in this field is very
limited and is to the best of our knowledge.
1.2 Purpose
The purpose of this study is (1) assess the knowledge, attitudes and behavioral practices of
groups of employees in restaurants (managers, chefs, servers and handlers), (2) determine the
association between food allergy knowledge, attitudes and practices (KAP) among restaurant
staff and workforce position, staff experience, restaurant classes, staff education level and
other factors.
2. Material and methods
2.1 Study design
A cross-sectional study that was conducted between October 2019 and February 2020 among
restaurant staff in Jordan involved managers, cooks and waiters. In this study, restaurants
were defined as facilities that prepare and serve foods or beverages to customers at stand-
alone restaurants and restaurants in hotels. Food carts, other mobile food units, temporary
food stands, supermarkets, restaurants in supermarkets or caterers were not included in the
study. Data were collected from 89 randomly selected restaurants in the administrative
jurisdiction of Amman.
2.2 Sample size and study participants
Due to the lack of a population sampling framework, the respondents were selected using
convenience sampling. The targeted sample size (n5300 respondents) was based on earlier
evidence which indicated that a sample size of (n5300 respondents) would likely provide
adequate statistical power for multivariate analyses (Radke et al., 2016). Data were collected
randomly without exclusion criteria regarding restaurant characteristics (e.g. no selection by
service type or food type) or geographic location. For participants, adult staff (>18 years old)
who were able to read and understand text written in Arabic and had more than one year of
work experience in a restaurant were eligible for the study, otherwise, they were excluded.
2.3 Research tool
A self-administered questionnaire used in assessing FA knowledge, attitudes and practices
among restaurant staff in Jordan was based on previous studies with some modification
(Ajala et al., 2010;Karajeh et al., 2005;Lessa et al., 2016;Loerbroks et al., 2019;Radke et al.,
2016). The questionnaire was initially developed in English and then translated into Arabic
by three independent translators with substantial experience in the health service industry.
Validation of the questionnaire content was performed by five foodservice and hospitality
industry professionals and edited based on their feedback. The questionnaire was piloted
face to face with 30 restaurant staff, and modifications were made to it based on these
preliminary findings. The questionnaire was comprised of four sections. The first section
included eight questions about socio- demographic characteristics and data related to the
restaurant. The second section included six knowledge questions related to food allergy
information. The third section included four questions related to staff attitudes, and the last
section included eight questions related to the correct actions needed to avoid cross-
contamination and how employees should deal with any mistake during work which might
affect the safety of food for consumption by allergic individuals. Responses were scored as
follows: correct response 51, incorrect response 50 and do not know 50. Bias induced by
Food allergy
KAP among
restaurant’s
staff
guessing was reduced by including “I do not know”as an answer choice. To enable response
quantification, four-degree values (never, scarcely, sometimes, always) were used, and these
were scored from 0 to 3, and where three-degree values (agree, neutral, disagree) were used,
these were scored from 0 to 2. All scores were converted to percentages, and the ordered
distribution of answers was divided into three parts, each containing 33% of the population
(tertiles). Based on the tertiles distribution, knowledge was divided into poor <50%, moderate
50–80% or excellent >80%. In addition, attitudes were characterized as negative <60%,
moderate 60–90% or positive >90%. Finally, behavioral practices were divided into those
that were high-risk <50%, moderate risk 50–75% or low-risk >75%.
2.4 Data collection
Data were collected by a trained team during personal visits to the restaurants. Face-to-face
meetings were first conducted with the managers for approximately 20 min. Permission to
collect data was obtained from the managers, workers who primarily prepared or cooked food
and waiters (those taking orders or serving food). The data collection team informed the
respondents by explaining the study aim, its impact on society and its confidential nature.
Verbal consent was given before filling the questionnaire. The participants completed a
questionnaire via a face-to-face meeting for 15 min, under the supervision of suitably trained
investigators. The participants autonomously completed the questionnaire, except for those
who requested clarification from the interviewer, those with low literacy or those who did not
have enough time to complete it.
2.5 Statistical analysis
Descriptive statistics were produced for the study participants and restaurant
characterizations by finding the frequencies n(%). The KAP categories were classified as
tertiles based on the results. Logistic regression models were used to examine the
associations between KAP, separately (the dependent variables) and participants’
characteristics plus the potential determinants of the restaurants approached (the
independent variables). To identify potential independent determinants of knowledge,
attitudes or practices, logistic regression models were also used. Multiple logistic regressions
were used for obtaining odds ratios (ORs). The ORs estimated the risk of having poor and
moderate knowledge, attitudes or practices, concerning to participant and restaurant
characterization variables. A confidence interval of 95% and p-value <0.05 were used to
determine the statistical significance. All analyses were carried out using Statistical Package
for Social Sciences (SPSS Inc., Chicago, IL, US), version.
2.6 Ethical approval
This study was approved by the ethics committee at the University of Petra. Jordan (Study
ID: 3Q/1/2020).
3. Results
3.1 Demographic characteristics of the participants and the potential determinants of the
restaurants
A total of 542 restaurant staff were approached, and 56.5% or 306 participants completed the
survey, with 43% declining, mostly due to a lack of time. The demographic features and
restaurant information are summarized in Table 1. The majority of the staff were male
(86.6%). About half of the participants were managers (47.7%). Moreover, 59.8% of the
respondents had received education up to the secondary level. Around 38% of the
participants had one to four years of experience in their current position, and 70.6% had not
BFJ
faced an allergy case during work. Regarding the restaurants, the majority (36.9%) of the
surveys obtained was collected from local or unclassified restaurants, while 34% were from
four or five-star restaurants. Most of the restaurants (68.3%) that were approached were
using either HACCP or ISO systems.
3.2 Restaurant staff knowledge, attitudes and practices concerning food allergy
From the results obtained, it was noted that most participants had either moderate (35.6%) or
excellent knowledge (35.9%) regarding FA. In addition, most of the participants had
moderate (37.3%) or positive attitudes (35.9%) and had a low percentage of high-risk
practices (24.5%) as shown in Table 2.
Variables N(%)
Gender Female 41 (13.4)
Male 265 (86.6)
Age ≤25 111 (36.3)
26–35 128 (41.8)
≥36 67 (21.9)
Experience (years) 1–4 117 (38.2)
5–9 97 (31.7)
≥10 92 (30.1)
Education level ≤Secondary school 123 (40.2)
>12 Secondary school 138 (59.8)
Position Manager 146 (47.4)
Chef 79 (25.8)
Waiter 81 (26.5)
Participated in food allergy training No 162 (52.9)
Yes, first aid training 86 (28.1)
Yes, regularly 58 (19.0)
Number of food allergic cases 0 216 (70.6)
<10 65 (21.2)
≥10 25 (8.2)
Restaurants characteristics
Food safety certificate No 97 (31.7)
Yes, HACCP or ISO 209 (68.3)
*Restaurant class No 113 (36.9)
≤3 stars 89 (29.1)
4–5 stars 104 (34.0)
*Note(s): Restaurant classification considered based on unique amenities and quality service in Jordan www.
mota.gov.jo
The categories of the restaurant staff’s KAP N(%)
Knowledge Poor knowledge <50 87 (28.4)
Moderate knowledge 50–80 109 (35.6)
Excellent knowledge >80 110 (35.9)
Attitudes Negative attitude <60 82 (26.8)
Moderate attitude 60–90 114 (37.3)
Positive attitude >90 110 (35.9)
Practices High-risk practice <50 75 (24.5)
Moderate risk practice 50–75 111 (36.3)
Low-risk practice >75 120 (39.2)
Table 1.
Characteristics of
study participants and
potential determinants
of the approached
restaurants (n5306)
Table 2.
Knowledge, attitudes,
practices (KAP)
categories of
restaurant’s staff
Food allergy
KAP among
restaurant’s
staff
3.3 Multiple-logistic regression analysis of food allergy KAP among the staff and their
characteristics and restaurant characteristics
3.3.1 Food allergy knowledge. Table 3 shows odds ratios for allergy knowledge based on the
participants’and restaurants’characteristics. The odds of having poor knowledge
(OR 54.72; CI:2.38 9.36) was higher among staff who had less than or the equivalent to
secondary school compared to the reference category (>80 or excellent knowledge). A similar
trend was observed for unclassified restaurants which were associated with an increased
odds ratio of poor knowledge (OR 50.26; CI: 0.094–0.743) compared to the reference category
(excellent knowledge). This means that the knowledge increased as the education level and
the restaurant class increased. Moderate food allergy knowledge was significantly associated
with staff age, position and restaurant classification. Increasing age was associated with a
reduction in the likelihood of moderate allergy knowledge by 0.954 units while holding all
other variables in the model constant. The waiters were more likely to have a moderate
allergy knowledge level compared with that of managers (OR 50.363; CI: 0.173–0.764).
3.3.2 Restaurant staff attitudes toward food allergy. Table 4 shows odds ratios for allergy
knowledge based on the participant and restaurant characteristics. Regarding the restaurant
staff attitude, the greater experience was associated with a reduction in the likelihood of
negative and moderate attitudes by 0.886 and 0.890 unit, respectively, but increasing age was
associated with an increased likelihood of moderate attitude by 1.006 unit when holding all
other variables in the model constant. Females were less likely than males to have moderate
rather than a positive attitude (CI:0.120–0.720). For the education level, staff with less than or
Variable
Poor knowledge (<50) Moderate knowledge (50–80)
BOR (95% CI) BOR (95% CI)
Age 0.013 1.013 (0.964–1.065) 0.047 0.954 (0.910–1.00)*
Experience 0.001 0.999 (0.928–1.076) 0.030 1.030 (0.961–1.104)
Gender
Female 0.639 0.528 (0.187–1.491) 0.700 0.496 (0.215–1.146)
Male ––
Education level
≥Secondary school 1.552 4.723 (2.382–9.362)* 0.397 1.487 (0.781–2.830)
<Secondary school ––
Position
Manager 0.754 0.471 (0.203–1.090) 1.012 2.75 (0.173–0.764)*
Chef 0.248 0.781 (0.320–1.903) 0.699 0.497 (0.218–1.136)
Waiter ––
Training
Number of food allergy cases 0.630 0.533 (0.265–1.071) 0.389 0.678 (0.356–1.292)
0––
≥1
Food safety certificate 0.729 2.073 (0.676–6.358) 0.945- 0.389 (0.156–0.970)
No ––
Yes, HACCP or ISO
Restaurant class 1.331 0.264 (0.094–0.743)* 0.085 0.918 (0.431–1.958)
No 0.050 0.951 (0.431–2.098) 0.430 0.650 (0.307–1.379)
≤3 stars ––
Notes:
a
Excellent knowledge (80<) is reference category; CI 5Confidence interval; OR 5Odds ratio.
*p-value <0.05
Table 3.
Multivariate logistic
regression of the
restaurant staff
characteristics and
restaurants
determinants with FA
knowledge
BFJ
equivalent to secondary school education had 3.804 times higher odds of having a negative
attitude (CI:1.901–7.611) and 2.173 times higher odds of having a moderate attitude (CI:1.149–
4.111) compared to the positive attitude category. Staff who worked in unclassified
restaurants and staff who had no food hygiene training or safety certificate had an increased
likelihood of a negative attitude (OR 53.695; CI:1.147–11.906), (OR 50.137; CI:0.046–0.414),
respectively.
3.3.3 Restaurant staff practices toward food allergy. Table 5 shows odds ratios for allergy
practices based on the participant’s and restaurant’s characteristics. Managers were less
likely to have high-risk practices compared to waiters (OR 50.425; CI:0.187–0.967). Staff who
had no food hygiene or safety certificates had 7.606 times higher odds ratio of having high-
risk practices (CI:2.717–21.289). Staff who worked in restaurants classified as ≤3 stars had
4.765 times higher odds ratio of having high-risk practices (CI:1.935–11.686).
4. Discussion
The main goal of this study was to determine food allergy KAP among restaurant staff in
Jordan. Further, work was designed to determine the characteristics associated with KAP
domains. The overall results revealed that most of the staff approached had either moderate
or excellent knowledge. The same trend toward FA attitudes was observed. Regarding FA
practices, participants mainly had either moderate or low-risk practices to deal with
Variable
Negative attitude <60 Moderate attitude (60–90)
BOR (95% CI) BOR (95% CI)
Age 0.051 1.052 (0.996–1.112) 0.064 1.066 (1.015–1.119)*
Experience 0.122 0.886 (0.814–0.963)* 0.117 0.890 (0.829–0.954)*
Gender
Female 0.818 0.441 (0.172–1.132) 1.220 0.295 (0.120–0.724)*
Male ––
Education level
≥Secondary school 1.336 3.804 (1.901–7.611)* 0.776 2.173 (1.149–4.111)*
>Secondary school ––
Position
Manager 0.371 1.450 (0.645–3.260) 0.633 1.884 (0.893–3.974)
Chef 0.565 0.569 (0.239–1.354) 0.046 0.955 (0.433–2.105)
Waiter ––
Training
Number. of food allergy cases
00.147 0.863 (0.431–1.726) 0.102 0.903 (0.481–1.698)
≥1––
Food safety certificate
No 1.307 3.695 (1.147–11.906)* 0.718 0.488 (0.197–1.211)
Yes, HACCP or ISO ––
Restaurant class
No 1.985 0.137 (0.046–0.414)* 0.300 0.741 (0.345–1.589)
≤3 stars 0.218 0.804 (0.361–1.791) 0.184 1.202 (0.569–2.539)
4–5 stars ––
Note(s):
a
Positive attitude (90≤) is reference category; CI 5Confidence interval; OR 5Odds ratio.
*p-value <0.05
Table 4.
Multivariate logistic
regression of
restaurant’s staff
characteristics and
restaurants
determinants with
attitudes regarding FA
among the staff
Food allergy
KAP among
restaurant’s
staff
consumers with food allergies. This result agreed with Radke et al. (2016) who reported that
managers, food workers and servers had a good level of knowledge regarding food allergies
in the US. Similar results were reported by another study in Malaysia, where the authors
concluded that most food handlers had only moderate levels of food allergy knowledge,
practice and awareness. However, only a small proportion of them had excellent food allergy
knowledge, practice and attitudes (Shafie and Azman, 2015). The multiple logistic regression
analysis of the present study identified many characteristics that were significantly
associated with poor knowledge of the restaurant staff regarding FA. These include
restaurant classification, staff age, education level and position. Most participants were
aware of the term “food allergy”, its definition, symptoms and common food allergens.
However, poor knowledge was associated significantly with a decrease in the education level.
This outcome may have been were affected by the high percentage of managers who
participated in this study. Higher positions of responsibility were associated with higher
education level and better
knowledge levels in the entire data set and, therefore, in the outcome. These results agree
with a similar cross-sectional study by Ajala et al. (2010) which revealed that managers
consistently had higher knowledge levels than waiters or servers. The results of the current
study were also in agreement with Loerbroks et al. (2019), who reported that increasing
knowledge of FA was associated with increases in the school degree obtained and also was
Variable
High risk practice <50 Moderate risk practice (50–75)
B
Exp(B)
(95% CI) B
Exp(B)
(95% CI)
Age 0.012 1.012 (0.957–1.071) 0.024 1.024 (0.983–1.067)
Experience 0.033 1.034 (0.955–1.119) 0.014 0.986 (0.925–1.052)
Gender
Female 0.102 0.903 (0.335–2.437) 0.584 0.558 (0.245–1.270)
Male ––
Education level
≥Secondary school 0.374 1.454 (0.724–2.919) 0.122 1.129 (0.628–2.031)
>Secondary school ––
Position
Manager 0.855 0.425 (0.187–0.967)* 0.442 0.643 (0.313–1.320)
Chef 0.639 0.528 (0.216–1.292) 0.197 0.821 (0.384–1.759)
Waiter ––
Training
Number. of food allergy cases
00.389 0.678 (0.331–1.390) 0.223 0.800 (0.437–1.465)
≥1––
Food safety certificate
No 2.029 7.606 (2.717–21.289)* 0.538 1.713 (0.641–4.579)
Yes, HACCP or ISO ––
Restaurant class
No 0.831 2.296 (0.845–6.237) 0.171 1.186 (0.583–2.415)
≤3 stars 1.559 4.756(1.935–1.686)* 0.373 1.452 (0.741–2.845)
4–5 stars ––
Note(s):
a
low-risk practice (75≤) is reference category; CI 5Confidence interval; OR 5Odds ratio.
*p-value <0.05
Table 5.
Multivariate logistic
regression of
restaurant staff
characteristics and
restaurant
determinants with FA
practices among
the staff
BFJ
associated with a greater understanding of details, such as food labeling regulations and
other food technical issues (Loerbroks et al., 2019). Similar results by the EHS-Net Study
(Radke et al., 2016) concluded that managers had higher knowledge scores than food workers.
Moreover, some business owners provide training regarding food issues, such as FA for
managers more frequently than for other staff which leads to higher knowledge levels among
managers (Shafie and Azman, 2015). In addition, knowledge was associated significantly
with increasing restaurant classification. Personnel of higher-class restaurants (such as four-
and five- star restaurants) were more likely to have excellent knowledge. This may have been
due in part to the high standards followed in the higher-classified restaurants that impose
mandatory training for staff based on the law and food safety requirements of systems, such
as HACCP, ISO 22000. From another point of view, more significant financial resources
available to these restaurants allow the attraction and retention of more knowledgeable staff
(Radke et al., 2016). Many studies suggested that knowledge level could be increased among
food handlers generally through particular education interventions regarding FA
management (Bailey et al., 2011;Loerbroks et al., 2019;Radke et al., 2016). Therefore, local
authorities such as the Food Control Directorate at the Jordan Food and Drug Administration
(JFDA) are responsible for preparing comprehensive and interactive educational programs
and workshops with essential information about food allergies for restaurant staff, especially
for those who have not received high levels of education (Sethi, 2016). On the other hand, local
health authorities in most countries are responsible for making food safety training
compulsory for food handlers to decrease the number of FA accidents in restaurants
(Loerbroks et al., 2019).
At present, “food allergen management”training courses in Jordan are not compulsory in
all food sectors, even for restaurants. These could be extended to include food handlers who
are working with restaurants that have HACCP or ISO 22000 certificates (or other food
systems). Studies have reported that some food handlers in the foodservice industry are
willing to take training on FA to increase their knowledge level (Lessa et al., 2016;Loerbroks
et al., 2019;Radke et al., 2016;Shafie and Azman, 2015). Regarding restaurant staff attitudes
and practices, little recent research is available (Lessa et al., 2016;Loerbroks et al., 2019;Radke
et al., 2016;Shafie and Azman, 2015). Most participants involved in the present study had
moderate or positive attitudes toward FA and they were either at low or moderate FA practice
risk levels. Multiple regression analysis identified that increasing years of experience,
education level, restaurant class and food safety certificate availability were associated with
an increase in excellent attitudes regarding FA. Similarly, the behavioral practices of food
handlers move toward less risk as the food handler’s responsibility increases, as the
restaurant class increases and as the availability of approved hygiene certificates occurs.
Restaurant staff attitudes may be affected by an increase in the amount of experience and
exposure to more FA cases during work. The high school degree may also stimulate staff to
look for better strategies to deal with customers having FA. Besides, staff attitudes are
affected by the exposure to educational materials that are provided for staff through
mandatory training. This result is consistent with those from a cross-sectional study that
reported FA training was associated with a positive manager or server attitudes (Radke et al.,
2016). As well as in the present study, females were more likely to have moderate attitudes
than males. Similar results were obtained by Loerbroks et al. (2019) who explained that the
greater capacity for empathy on a female’s part makes her more open toward nutritional
issues, healthier diets and have greater nutritional competence compared to her male
counterparts (Loerbroks et al., 2019). Moreover, an EHS-Net study concluded that there was a
significant difference between managers and food workers regarding the FA attitudes, and
the mangers had lower attitude scores than other food workers (Radke et al., 2016). However, a
recent study found that the restaurant staff had unfavorable attitudes, and they did not prefer
to deal with FA cases due to limited self-confidence in terms of their ability to accommodate
Food allergy
KAP among
restaurant’s
staff
the needs of customers with food allergies (Loerbroks et al., 2019). Overall, a significant
number of allergic reactions to food occur each year, and some of these reactions are fatal and
caused by food from a restaurant or other food service establishment (Radke et al., 2016). All
restaurant staff, including managers, food workers and servers play crucial roles in the
prevention of allergic reactions to food in their workplaces. Managers can develop safe plans
for serving customers who have any type of food allergy, provide training for all staff to
increase their knowledge regarding FA and develop alternative menus for FA customers.
Restaurant staff, such as servers and waiters can describe the menu for FA customers and
control meal preparation and presentation to prevent allergen cross-contamination (Radke
et al., 2016). Good communication between these groups can result in a safe meal being served
to FA consumers. Providing safe meals for FA customers will return many benefits to
restaurants by broadening the consumer base, acquiring the loyal patronage of those with
food allergies in the community, preventing harm to their clientele and avoiding lawsuits
(Radke et al., 2016)
.
5. Conclusion
5.1 Summary
In conclusion, the results of this study achieved the study purpose. It was found that
most restaurant staff had either a moderate or excellent level of food allergy knowledge
and attitudes with a low or moderate risk level of behavioral practices toward FA.
The knowledge level among staff was mainly associated with their education achieved,
workforce position and experience, restaurant classes where employed and the presence of
food safety and management system certificates. The outcome of this study will be useful in
understanding the current situation of food allergy knowledge, attitudes and practices
among staff in Jordanian restaurants and contribute to the development of appropriate
educational tools and strategies to raise the knowledge level of the staff, improve their
attitudes and practices to ensure the safety of meals for FA customers. In addition,
understanding the relationship between knowledge, attitudes and practices is critical to
create and develop effective interventions. Managers need to act as role model team players
to inspire, train, teach other staff and therefore need to acquire a good knowledge level to
develop correct attitudes, skills and work habits (KASH), which will lead to the introduction
of safe meals for FA customers. The competencies among the restaurant staff are necessary
for developing KASH among staff to deal successfully with FA cases. The KASH attributes
are relevant to all staff in an organization, but every staff position has critical specific
attributes that help the organization function better (Sethi, 2016). Despite this, customers
with FA will continue to be at high risk of poor understanding of food allergen risks, poor
knowledge of appropriate controls and high-risk practices among the restaurant staff.
Therefore, the lack of training is the most significant problem. Even though the survey
showed that food handlers had some knowledge of FA, allergic people must stay on the alert,
questioning the place where they are going to have their meals in terms of the ingredients
used, verifying whether the food is free of allergens and always observing the labels on food
products where available. Additional research is needed to explain these observations and
search for other determinants of KAP. The participation of government agencies is also
crucial for the development of educational programs regarding FA for food handlers who
work in any organization preparing food.
5.2 Strengths and limitations
To the best of our knowledge, this is the first study conducted in Jordan assessing the KAP
levels of restaurant staff regarding FA. The study analysis was based on 306 participants,
BFJ
which is an appropriate sample size, giving more power to detect KAP categories and KAP
determinants among the restaurant staff. The participants in this study were chosen
randomly, therefore, the staff data might be representative of these groups. Finally, the
statistical analysis of this study predicts the factors that may be related to the restaurant staff
KAP. Therefore, this result could help the local authority to design educational materials
based on these results; for example, for unclassified restaurants or re-structuring restaurants,
the staff in the Jordanian restaurants should be required to know what is necessary to provide
safe meals for FA consumers. On the other hand, there were a few limitations. Participation in
this study was potentially is biased by a desire to be viewed as socially responsible. This
would imply, therefore, that the observations reported regarding negative attitudes represent
an underestimation of the true prevalence. Restaurant type and location were not taken into
consideration in this study. These characteristics might be associated with the KAP levels
among the restaurant staff in Jordan. Moreover, this study used self-administered
questionnaires which may have affected the results. Finally, we collected the data from the
capital of Jordan, a single large city; therefore, these data are likely representative of the study
area, but not necessarily for other cities.
List of Abbreviations
CI Confidence Interval
FA Food Allergy
FDA Food and Drug Administration
HACCP Hazard Analysis and Critical Control Points
IgE Immunoglobulin E
ISO International Organization for Standardization
JFDA Jordan Food and Drug Administration
KAP Knowledge, Attitudes and Practices
KASH knowledge, Attitudes, Skills and work Habits
OR Odds Ratio
SD Standard Deviations
WAO World Allergy Organization
References
Ajala, A.R., Adriano, G., Cruz, J.A.F., Faria, E.H.M., Walter, D.G., Anderson, S. and Sant0, A. (2010),
“Food allergens: knowledge and practices of food handlers in restaurants”,Food Control,
Vol. 21 No. 10, pp. 1318-21.
Bailey, S., Albardiaz, R., Frew, A.J. and Smith, H. (2011), “Restaurant staff’s knowledge of anaphylaxis
and dietary care of people with allergies”,Clinical and Experimental Allergy, Vol. 41 No. 5,
pp. 713-17.
Bunney, P.E., Zink, A.N., Holm, A.A., Billington, C.J. and Kotz, C.M. (2017), “Orexin activation
counteracts decreases in nonexercise activity thermogenesis (NEAT) caused by high-fat diet”,
Physiology and Behavior, Vol. 176 No. 9, pp. 139-48.
Centers for Disease Control and Prevention (2013), Voluntary Guidelines for Managing Food Allergies
in Schools and Early Care and Education Programs, US Department of Health and Human
Services, Washington, DC.
Din, N., Rashid, B., Kamal Izzuwan, R. and Che Noriah, O. (2018), “Approaches of improving food
allergy knowledge: children with food allergy’s quality of life”,Environment-Behaviour
Proceedings Journal, Vol. 3 No. 7, p. 13.
Ferraro, V., Zanconato, S. and Carraro, S. (2019), “Timing of food introduction and the risk of food
allergy”,Nutrients, Vol. 11 No. 5, p. 1131.
Food allergy
KAP among
restaurant’s
staff
Iweala, O.I., Choudhary, S.K. and Commins, S.P. (2018), “Food allergy”,Current Gastroenterology
Reports, Vol. 20 No. 5, p. 17.
Karajeh, Mohammed, A., Hurlstone, D.P., Patel, T.M. and Sanders, D.S. (2005), “Chefs’knowledge of
coeliac disease (compared to the public): questionnaire survey from the UK”,Clinical Nutrition,
Vol. 24 No. 2, pp. 206-10.
Lef
evre, S., Abitan, L., Goetz, C., Frey, M., Ott, M. and de Blay, F. (2018), “Multicenter survey of
restaurant staff’s knowledge of food allergy in Eastern France”,Allergo Journal International,
Vol. 28 No. 2, pp. 57-62.
Lessa, K., M Lozano, M.E. and Frigola, A. (2016), “Food allergy knowledge, attitudes and practices: a
pilot study of the general public and food handlers”,European Journal of Nutrition and Food
Safety, Vol. 6 No. 2, pp. 58-64.
Licari, A., Manti, S., Marseglia, A., Brambilla, I., Votto, M., Castagnoli, R., Leonardi, S. and Luigi
Marseglia, G. (2019), “Food allergies: current and future treatments”,Medicina, Vol. 55 No. 5,
p. 120.
Loerbroks, A., Julia Tolksdorf, S., Martin, W. and Smith, H. (2019), “Food allergy knowledge, attitudes
and their determinants among restaurant staff: a cross-sectional study”, in De Houwer, J. (Ed.),
Plos One, Vol. 14 No. 4, e0214625.
Radke, T.J., Laura, G.B., Hoover, E.R., Faw, B.V., Reimann, D., Wong, M.R., Nicholas, D., Barkley, J.
and Ripley, D. (2016), “Food allergy knowledge and attitudes of restaurant managers and staff:
an EHS-net study”,Journal of Food Protection, Vol. 79 No. 9, pp. 1588-98.
Sethi, M. (2016), Institutional Food Managment, New Age International (P), Dlehi.
Shafie, A.A. and Azman, A.W. (2015), “Assessment of knowledge, attitude and practice of food
allergies among food handlers in the state of penang, Malaysia”,Public Health, Vol. 129 No. 9,
pp. 1278-84.
Stoneman, S. (2018), Food Allergy Awareness Training for the Food Service Industry, Virginia
Polytechnic Institute and State University, Blacksburg.
Wang, J. and Sampson, H.A. (2009), “Food allergy: recent advances in pathophysiology and
treatment”,Allergy, Asthma and Immunology Research, Vol. 1 No. 1, pp. 19-21.
BFJ
Appendix 1
Section/ question Response
Knowledge section (K)
What is food allergy means? (1) Bowel disease due to excessive certain types of
food
(2) Non-hereditary bowel disease
(3) Small bowel damage is a fatal disease
(4) Diseases occurs due to immune response to
some food
What are the symptoms of food allergy? (1) Unconsciousness
(2) Itch or rash
(3) Irregular pulse and difficulty
(4) Breathing
(5) Urination
(6) All the above - I do not know
Which people are considered at food allergy risk? (1) Children only
(2) Adults with genetic factors
(3) Adults only
(4) Elderly people only
(5) All
(6) I do not know
What is the diagnosis of food allergy? (1) Skin allergy symptoms
(2) Laboratory tests
(3) Endoscopic surgery
(4) Fever as a symptom
(5) I do not know
What is the most common food that cause allergy? (1) Wheat and its products
(2) Milk and egg
(3) Some seafood and fish
(4) Nuts and legumes
(5) Fruit
(6) Vegetable
(7) All
(8) I do not know
How long is the time required for the appearance of
the symptoms that associated with food allergy?
(1) Within minutes
(2) From two minutes to 12 h
(3) Within 2 days
(4) In minutes to two hours
(5) I do not know
Attitudes (A)
The persons can eat the allergen food in small
amount?
(1) Agree
(2) Neutral
(3) Disagree
The allergen substances do not move or cross from
place to place (cross-contamination)
(1) Agree
(2) Neutral
(3) Disagree
High temperature destroys the allergen on food (1) Agree
(2) Neutral
(3) Disagree
The following sentence “may contain cretin food
allergen in the product label”means that this food is
preferred for allergy sufferers
(1) Agree
(2) Neutral
(3) Disagree
(continued )
Table A1.
Food allergy
knowledge, attitudes
and practices (KAP)
among restaurant staff
questionnaire
Food allergy
KAP among
restaurant’s
staff
Corresponding author
Nour Amin Elsahoryi can be contacted at: nour.elsahoryi@uop.edu.jo
For instructions on how to order reprints of this article, please visit our website:
www.emeraldgrouppublishing.com/licensing/reprints.htm
Or contact us for further details: permissions@emeraldinsight.com
Section/ question Response
Practices (P)
Did you ask the customer if she/he has any food
allergy?
(1) Ever
(2) Scarcely
(3) Sometimes
(4) Always
Did you have special policy to deal with food allergy
requests and prepare meal for any food allergen
customer?
(1) Ever
(2) Scarcely
(3) Sometimes
(4) Always
Did you read any food label through the products
receiving or /and food preparing to check on the food
allergen?
(1) Ever
(2) Scarcely
(3) Sometimes
(4) Always
When receiving and storing the food in your
institution, did you take care to separate food allergy
items from the other food items to prevent cross-
contamination?
(1) Ever
(2) Scarcely
(3) Sometimes
(4) Always
Do you distinguish between a normal dish and a dish
for an allergy customer in any way?
(1) Ever
(2) Scarcely
(3) Sometimes
(4) Always
If a person who has lactose intolerance and he ate cake
prepared with cow milk at the restaurant accidently
during your work time, what should you do first?
(1) I help him puke
(2) Bring a cup of water
(3) Contact the workplace official
(4) Waiting to see if he has an allergic reaction
(5) Call 911
(6) I do not know
If you only have one grill to prepare orders, what is a
good way to avoid mutual contact and pollution to
prepare a dish that is free from allergens?
(1) The heat kills the allergens, and therefore,
mutual contact cannot occur on the grill
(2) Wipe the grill before preparing allergy-free food
(3) Use barbecues to act as a barrier to separate
food allergens-free from the surface of the grill
(4) Grill allergy-free food first
(5) I do not know
A customer who is allergic to peanuts, ordering a slice
of brown cake. Accidently, one of the staff added a
scoop of peanut butter ice cream to the cake. How
should the staff handle this request?
(1) Use tensile-free tongs to remove the cake from
the dish
(2) Remove the peanut-containing ice cream away
with a clean towel
(3) Submit the application with additional ice cream
as a kind of tip
(4) Completely change the dish
(5) I do not know
Table A1.
BFJ
