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In the United State over 15 million children attend a childcare facility annually. These children are 3.5 times more likely to contract a foodborne illness than children cared for in other settings. Proper hand hygiene practices have been identified as the most important practice to mitigate the spread of foodborne illnesses. Thus, the aim of this study was to explore hand hygiene training opportunities given to childcare food handlers in childcare facilities; as well as explore what food safety training childcare directors currently possess. Results showed directors received food safety training yet did not always pass the training along to their employees. A lack of written hand hygiene policies was identified, as well as lack of childcare employee training for hand hygiene on the topics of hand washing and glove use. It is recommended that childcare directors communicate the importance of proper hand hygiene through microlearning food safety interventions.
Keywords:Childcare; Food safety; Foodservice; Hand hygiene; Training
Though ample research has been conducted pertaining to food safety and handling practices with numerous interventions tested, foodborne illness outbreaks continue to persist. The four pathogens identified most often in foodborne illness outbreaks are Norovirus (5.5 million), Nontyphoidal Salmonella spp. (1.0 million), C. Perfringens (1.0 million), and Campylobacter spp. (0.8 million) . Of the approximately 5.5 million cases of Norovirus annually, 149 cases result in death and costing over $2.2 billion in economic burden . Among American children under five years of age, Norovirus has been the leading cause of medical visits for acute gastroenteritis  and costs an estimated $273 million due to 14,000 hospitalizations, 281,000 emergency room visits, and 627,000 outpatient visits annually. Aside from the economic burden, foodborne illness can lead to severe short-term and long-term health consequences, such as vomiting, diarrhea, organ failure and, in some cases, death.
Annually, over 15 million children attend a childcare facility in
the United States . On average, these children spend 33 hours per week in some type of childcare facility . Many childcare facilities provide breakfast, lunch, and snacks. Some facilities had designated foodservice employees, while others utilize teachers or parents to supply or prepare food. Each of these methods may be susceptible to unsafe food handling practices resulting from improper hand hygiene.
Research has shown children are 3.5 times more likely to contract FBIs in childcare facilities compared to children cared for in their own homes . It has also been estimated that acute gastrointestinal illnesses associated with childcare facilities cost over $2.3 billion annually . The American Academy of Pediatrics notes the close proximity of children in childcare facilities and their natural curiosity to touch a wide range of objects and surfaces only heightens their risk of infection . Additionally, transmission of enteric pathogens in childcare facilities occurs
from person-to-person contact (hand hygiene) due to the close
interaction necessary in the care of children, particularly in
diapering, toileting, and food service [7,8].
In childcare facilities, researchers have previously investigated
food safety knowledge, attitudes toward safe food handling
practices, food handling practices, as well as microbial analysis
of food contact surfaces and hand hygiene. Wohlgenant et al. 
examined hygiene and sanitation practices of childcare employees
during food preparation in the kitchen as well as during food
service in the classrooms to identify pathogen dissemination
points. Researchers found the most out of compliance practices
were food handlers wearing effective hair restraints, food
handlers wearing gloves, sanitizer test kit available for facilities
that wash dishes by hand, and availability of a food thermometer.
Additionally, microbial analysis showed childcare facilities without
a written food preparation policy had significantly higher aerobic
plate counts on all surfaces . Kotch et al.  identified that
proper equipment in hand washing and food preparation areas
designed to reduce the spread of infection had a significant effect
on reducing illness among the children. The need for childcare
workers to follow correct procedures to protect children from any
harm, including foodborne illness, remains extremely important
Childcare employees play a crucial role in children’s health
and safety  and must actively work to prevent FBI outbreaks
. For example, Fraser et al.  used observations to identify
frequency of surfaces touched by childcare providers. Staskel, et
al.  observed childcare cooks demonstrating lack of proper
hand washing, nearly 50% used improper techniques. Cosby
et al.  surveyed bacteriological contamination on selected
food contact and non-food contact areas in childcare centers. Li
et al.  combined observational and microbiological analysis
showing facilities without a written food preparation policy had
significantly higher microbial contamination on all surfaces than
facilities with a written food preparation policy. Kinnula, et al. 
investigated the use and safety of alcohol-based hand gels (AHGs)
among children in childcare centers; Zomer et al.  observed
childcare employees’ compliance to hand hygiene guidelines and
identified environmental determinants of hand hygiene behavior.
Roberts et al.  showed through a hand hygiene intervention
that proper hand washing in childcare facilities greatly reduced
rates of respiratory and diarrheal illness. Hand washing by
childcare employees has been identified as the single most
important preventative measure to avoid infecting themselves
and children with harmful pathogens [20,21].
Thus, the specific research objectives for this exploratory
study were to:
1. Assess hand hygiene training opportunities given to
childcare food handlers in childcare facilities.
2. Identify what food safety training childcare directors
The target population for this study was licensed center-based
childcare directors in a South Eastern state. Licensed center-based
childcare facilities including commercial, church, and preschools.
99 childcare directors were randomly selected from a database of
all licensed center-based childcare facilities in the state.
A paper-based questionnaire adapted from  was
utilized, consisting of 9 questions to identify childcare facility
demographics, and evaluate childcare facility food safety training.
The childcare facility demographics section contained 3 questions
including: type of childcare facility (i.e. independently owned or
operated, chain/franchise); number of food handling employees;
and current enrollment. The childcare facility food safety training
section contained 6 questions pertaining to food safety policies (2
questions); and food safety training (4 questions).
To reduce sampling error and increase participation rates
a survey implementation plan was utilized . In the initial
mailing a packet containing:
• Director cover letter.
• Director questionnaire informed consent form.
• Director paper-based questionnaire; and
• Prepaid addressed return envelope. Follow-up contacts
spaced approximately one week apart for three weeks, were used
to recruit participants . Replacement questionnaires were
offered. A final telephone contact to childcare directors was made
to those childcare facilities who had not responded.
Data were analyzed using SPSS (Version 23.0). Descriptive
statistics including mean, standard deviation, frequency, and
percentage were used to summarize the data.
A total of 68 of the 99 director questionnaires distributed were
completed, for a response rate of 68.7%. The majority of facilities
were reported as independently owned/operated (64.7%), withover 60% having 15 employees or fewer, as well as nearly 85% of
facilities had 200 or less children enrolled (see, Table 1).
All but two (97%) childcare directors stated they have food
safety hand hygiene policies in place, yet 24 directors stated
they do not have written hand hygiene policies (see, Table 2).
Current study results are higher than previous childcare research,
in which 83% of centers reported written procedures for hand
washing . The American Academy of Pediatrics’ (2011)
recommends having written food handling policies, as they have
been shown to increase compliance with proper food handling
. The distinction between having “hand hygiene policies”
and having “written hand hygiene policies” is important, as the
ability to communicate these policies with employees in the form
of written procedures has been shown to improve hand hygiene
practices [24,25]. Furthermore, previous research has identified
the need for clear communication from the director on food safety
practices . Of the 68 respondents, 88.2% (n=60) stated they
had previously received food safety training, with 70.6% (n=48)
receiving a food safety certification as well. The importance of
having a director (manager) with proper food safety education
has been identified as critical to ensure employees following
proper food safety practices . In a study assessing food
safety culture in childcare facilities, findings showed childcare
employee’s ability to speak freely about food safety practices and
communication from directors to employees had a positive effect
on employees’ self-commitment to following proper food safety
practices . In other words, childcare employees need to feel
comfortable speaking and asking questions to the director about
food safety practice. However, just as important the director needs
to have the food safety knowledge to answer the questions and
communication appropriate food handling practices. Previous
research in the restaurant setting exploring the influence of
food safety climate indicators on hand washing practices found
managerial commitment significantly correlated with hand
washing frequency . However, finds also showed management
rewarding of hand hygiene practices was not related to hand
washing frequency. Similar findings were shown in a study on
the perceptions of a video game to promote proper hand washing
practices, in which respondents did not perceive the video game
rewarding or helping to motivate them to increase their hand
washing frequency or efficacy  (Table 2).
In the current study, over 30% of childcare directors (n=21)
reported not providing any training on food safety hand hygiene.
Of the 47 directors who reported providing training, 44 (64.7%)
indicated providing hand washing training and/or 31 (45.6%)
indicated discussing proper glove use as a training topic. These
findings are lower than previous childcare hygiene research, in
which facility directors reported 94% of centers provided initial
food safety training .
Due to the high-risk population (young children) in which
these childcare employees serve, the need for hand hygiene
training to ensure proper food safety handling practices is crucial.
Yet current study results show that less than half of directors
discuss proper glove use, which could potentially mitigate the
spread of foodborne microorganisms. It should also be noted that
initial hand hygiene training during new hire orientation is not
enough to ensure continuous proper food handling practices. In
their research in childcare facilities, Park et al.  found the need for further education for the more tenured (10+ years) childcare
cooks on proper food safety practices. On-going training and food
safety interventions are recommended to ensure new employees
are aware of and follow proper food handling practices, but also
more tenured employees should receive refresher interventions
on food handling practices.
Previous research investigating childcare employees’
perceived barriers to following food safety practices identified
respondents perceived they did not need to follow safe food
handling practices . This reinforces the importance of the
childcare director’s role in communicating not just the “how to
handle food properly”, but also the “why food should be handled
properly”. Furthermore, previous research has also suggested
“evidence-based and customized education and support
programs” should be created for educating childcare employees
In a systematic review of foodservice industry food safety
training topics & modalities findings showed the average length of
training intervention was 6.5 hours . However, “lack of time”
and “too much work to do” have been identified as key barriers
to following food handling practices and barriers to providing
training [25,31]. Therefore, directors need to identify food safety
training or interventions that are short as well as inexpensive.
A feasible approach to mitigate identified barriers to training
in childcare could be to create multiple short single topic multimodality
training interventions (microlearning modules), which
combined create a food safety education library. Each of the
microlearning training interventions can be completed quickly
and can be directly reinforced while on the job the same day.
Dolasinski & Reynolds  developed a microlearning model
applied in the hospitality industry. The authors identified
several benefits to utilizing a microlearning approach including
inexpensive, quick content delivery, and effective for on-thejob
service training. For example, for childcare hand hygiene, a
microlearning topic could be “how to wash your hands” (single
topic) utilizing an educational poster, short video, and 2-minute
director demonstration (multi-modality). This should then be
reinforced by the director through observation. This single topic
can then be combined with similar hand hygiene topics (when
to wash hands, hand sanitizer usage, etc...) to create a larger
hand hygiene educational library. This concept can be replicated
for various food safety topics (hand hygiene, personal hygiene,
temperature controls, etc…) in the childcare setting, as they are
inexpensive, short, and provide immediate customized practical
Proper hand hygiene practices have been identified as the
most important practice to mitigate the spread of foodborne
illnesses. Thus, the aim of this study was to explore hand
hygiene training opportunities given to childcare food handlers
in childcare facilities. Additionally, the manager of an operation
(childcare director) has a major role in the food safety program
at each facility. Therefore, this study also looked to explore what
food safety training childcare directors currently possess. Key
finds showed directors reported having hand hygiene policies, yet
over one third lacked written hand hygiene policies. Additionally,
most childcare directors received food safety training, however
over 30% did not provide their food handling employees and
hand hygiene training. Only slightly more than half the directors
reported providing hand washing training, while even fewer
provided glove use training.
The results show a clear need for increased childcare food
handling employee hand hygiene training. Previous barriers
of lack of time and funds have been identified. Yet, childcare
directors can utilize microlearning to educate employees on
hand hygiene using short, inexpensive, single content modules to
mitigate these barriers. The microlearning training can be tailored
to the facility’s needs and can be deployed easily on-the-job. Hand
hygiene training must be ongoing as well as director observations
should occur to ensure continuous proper handling practices.
This study was not without limitations. First, this was a
snapshot of childcare directors in one state, at one particular
moment. It should be noted that each state creates their own food
safety regulations for childcare inspections, thus generalization is
cautioned. Additionally, only center-based directors were targeted
as home-based facilities are generally smaller and only have one
or two employees. However, the current study’s exploratory
results help to identify the lack of consistent training for the
childcare director as well as the childcare food handler. Future
research should assess the use of short customized food safety
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Fraser A, Wohlgenant K, Cates S, Chen X, Jaykus L, et al. (2015) An observational study of frequency of provider hand contacts in childcare facilities in North Carolina and South Carolina. American Journal of Infection Control 43(2): 107-111.
Staskel DM, Briley ME, Curtis SR (2007) Food safety knowledge and behaviors of cooks in Texas childcare centers. Food Protection Trends 27(2): 90-94.
Roberts L, Jorm L, Patel M, Smith W, Douglas RM, et al. (2000) Effect of infection control measures on the frequency of upper respiratory infection in childcare: a randomized, controlled trial. Pediatrics 105(4): 738-742.
Pickering LK, Baker CJ, Kimberlin DW, Long SS (2012) Children in out-of-home childcare. Red book: Report of the Committee on Infectious Diseases. (29th edn). Elk Grove Village, IL: American Academy of Pediatrics, pp. 133-152.
Clark J, Crandall P, Reynolds J (2019) Exploring the influence of food safety climate indicators on handwashing practices of restaurant food handlers. International Journal of Hospitality Management 77: 187-194.
Park HR, Kim HM, Lee Y, Jeong SY, Lim YS (2017) Sanitation management of cooks in childcare centers in South Korea according to working duration and the type of childcare center: Importance-Performance Analysis. Food Control 73: 1452-1458.
Reynolds J, Dolasinski MJ (2019) Systematic review of industry food safety training topics & modalities. Food Control 105: 1-7.