Assessment of sanitary status of food and drinks catering establishments: A descriptive observational study in south East Asmara, Eritrea, 2019

Objective: Lack of basic infrastructure, poor practices of hygiene in food service establishments can contribute to outbreaks of foodborne illnesses. The aims of this study was to explore the sanitary conditions of food and drink catering establishment services in South East Asmara, Eritrea. Methods: A descriptive observational study was conducted among 139 food and drinks catering establishments in South East Asmara from June to September 2019. Data were collected using semi-structured questionnaire for obtaining socio-demographic information of the manager or owner and observation checklist was used to assess the overall physical sanitary status of the establishment. Factors infl uencing vermin infestation, kitchen and latrine cleanliness were further investigated. Data analysis was done using SPSS version 22. The descriptive results were summarized using frequencies and percentages in tables and graphs. Dining premises, kitchens and stores were categorized as clean, if the fl oor, wall, and ceiling of the premises were found clean. Moreover, bivariate and multivariate logistic regression analysis were done to fi nd out the main factors infl uencing vermin infestation, kitchen and latrine cleanliness. Results: Out of the total 139 food and drink catering establishments assessed, about one-tenth (8.6%) of the establishments’ dining room, a third (33.3%) of the stores and 31.5% of the kitchens were in a poor and unclean sanitary conditions. Good premise fl oor status (AOR=18.03; 95%CI (2.09-155.1), P<0.05), availability of adequate light (AOR=5.02; 95%CI (1.01, 24.99), P<0.05), running water (AOR=0.26; 95%CI (0.09, 0.72), P<0.05) and dustbin availability (AOR=4.32; 95%CI (1.06, 21.6), P<0.05) were found having signifi cant association with overall cleanliness of the kitchen. Two-third (65%) of the establishments’ latrines were clean. Availability of separate latrine for male and female (AOR=2.34; 95%CI (1.06, 5.18), P<0.05), and separate latrine for clients and workers (AOR=3.41; 95%CI (1.10, 10.57) were the main factors potentiating latrine cleanliness. More than a third (37.4%) of the establishments were found to be infested by vermin. Nearer kitchen distance from latrine (AOR=3.65; 95%CI (1.60, 8.35), p<0.05), presence of pets (AOR=4.1; 95%CI (1.17, 14.40), and breeding of insects in the liquid waste disposal (AOR=4.08; 95%CI (3.37, 12.17), p<0.01) had signifi cantly increased the presence of vermin infestation. Conclusion: The sanitary condition of the food and drinks catering establishments in the study area was found to be poor. There is a need to impose regulations and guidelines governing the basic sanitary requirement of the food and drinks catering establishments. Research Article Assessment of sanitary status of food and drinks catering establishments: A descriptive observational study in south East Asmara, Eritrea, 2019 Idris M Idris1*, Samuel J Wolday2, Amanuel T Ghebremariam2, Habtom Kidane3, Misgina Leake3, Hagos Milkias3 and Kahsay Ghebremichael3 1Department of Anesthesia, Orotta National Referral Hospital, Asmara, Eritrea 2School of Nursing, Asmara College of Health Sciences, Asmara, Eritrea 3School of Public Health, Asmara College of Health Sciences, Asmara, Eritrea Received: 28 September, 2020 Accepted: 16 October, 2020 Published: 19 October, 2020 *Corresponding author: Idris M Idris, MSc, MPH, Department of Anesthesia, Orotta National Referral Hospital, Asmara, Eritrea, Tel: 00291729695: Email:


Background
Annually, food borne diseases affects up to 30% of the populations in developed countries and kills millions in developing countries [1]. Food borne diseases are common in developing countries due to the prevailing poor food handling and sanitation practices, inadequate food safety laws, weak regulatory systems, lack of fi nancial resources to invest safer equipment, and lack of education for food handlers [2]. It is depicted that around 70% of diarrhea cases in developing countries were attributed to food-borne routes. On the top of its morbidity and mortality, worldwide fi nancial expenses of foodborne diseases is hard to be determined [3]. Due to the increments in the cases of food borne outbreaks, food safety has increasingly gaining attention of authorities worldwide [4]. Occurrence of food borne illnesses can be attributed to many socio-demographic and environmental factors, handling process of food preparation being the main factor [5]. Good hygiene practices include proper storage of food items, maintenance of clean environment during food preparation, and assurance of clean and free of bacteria dishes served [6]. Food safety is defi ned as the assurance that, when food is consumed in the usual manner does not cause harm to human health and wellbeing [7]. Poor food and drink catering establishments, and irresponsible food handlers are considered as sources of food borne illnesses [8]. Lack of basic infrastructure, poor knowledge about hygiene, absence of potable water, lack of proper storage facility and unsuitable environments for food operations (such as proximity to sewers and garbage dumps) and inadequate facilities for garbage disposal are considered factors compromising food safety [9]. Moreover, poor sanitary practices in food storage, handling, and preparation can create an environment in which bacteria and other infectious agents are more easily transmitted [10][11][12]. Poor personal hygiene could also contribute to foodborne illness, indicating that food handlers' knowledge and their handling practices is quite important [13]. It is suggested that improper food handling practices contribute to about 97% of food borne illnesses in food services establishments and homes [14]. Therefore, to reduce foodborne illnesses, it is crucial to explore the sanitary and hygienic conditions of food providing services [15]. Ensuring safe food service has been one of the major challenges and concerns for producers, consumers and public health offi cials [16]. In Eritrea, even though there is no published data available about food safety, it is assumed that every year many people suffer and even die to the intake of contaminated food and water. Based on the records of the ministry of tourism, the total number of customers utilizing food and drink establishments in South East Asmara (SEA) per day was 11,260 [17]. This suggests that the health and wellbeing of such a big number of people subsequently depends on the sanitary status of the catering establishments. The aim of this study was therefore to obtain current information on the sanitary conditions of food and drinks catering establishment services in South East Asmara (SEA).

Study design and setting
Descriptive observational study design was used to assess the sanitary conditions of food and drink catering establishment services in South East Asmara from June to September 2019.

Study population
The study and source population were all food and drink catering establishments situated in South East Asmara. Establishments which had full-fi lled the selection criteria were included in the study.

Selection criteria
The included subjects were all type of establishments licensed and registered by the ministry of tourism to provide both food and drink services. Whereas establishments not registered and licensed by the Ministry of Tourism, that serve only bottled drinks, like bars, and whose owners or managers were not willing to be participants in the study were excluded.

Sample size estimation
The sample size was determined using a single population proportion by assuming that 50% proportion of the food and drink establishments practiced safe and clean procedures with 95% confi dence interval and 5% margin of error. Using population correction formula and adding non-response rate the sample size was 139 establishments.

Sampling design
The research was done using a stratifi ed random proportionate to size method. The total list of all food and drink establishment services which are found in SEA was obtained from Ministry of Tourism; the establishments were then stratifi ed in to fi ve strata based on the type of service they provided. The fi ve type of establishments were: restaurants, hotels, juice/coffee shops, snack bars and fast food places. Sampling frame was prepared for each stratum. Then the sample was distributed to each stratum proportional to its size.
Finally, simple random sampling was used to select individual sample (Figure 1).

Data collection instrument
A Semi structured questionnaire was used to interview the manager/owner for obtaining socio-demographic information. This was pretested to ensure its consistency, validity and reliability. Observation checklist adopted from extensive literature review and from checklists used by Ministry of Tourism and Ministry of Health was used to assess and/or observe the overall physical sanitary status of the establishment. Observation checklist focused on assessing food premise's physical condition, handling cleanliness and Citation: Idris

Data analysis procedure
Data entry was done using CSpro version 6.3, then the data was exported to statistical package for social sciences (SPSS)

Socio demographic information of the managers
A total 139 managers were interviewed and 139 food and drink establishments were observed. Majority of the managers were males (69.1%), married (74.8%), younger age (38.8%), and have reached secondary school (48.9%). Though nearly half (47%) of the managers were owners, about 72% have never been trained about food hygiene. Yet, more than half of the mangers (52.5%) work as food handlers (Table 1).

Environmental factors and physical sanitary status of the food premises
Out of the total 139 establishments, the highest number of establishments type were restaurants (41.7%), followed by snack bars (23.7%), fast food places (19.4%), hotels (8.6%), and Coffee/Juice shops (6.5%). There was separate rooms for each food premises in majority of the establishments (80.6%), whereas the rest 19.4% didn't have separate kitchen or store for raw food. Majority of the establishments were newly constructed (89.9%), individually owned (87.1%), and had the requirements for hiring food handler (92%). However, only half of the establishments (49.7%) have never been inspected for sanitary conditions ( Table 2).

Repair conditions and cleanliness of dining rooms, store and kitchen premises
Among the assessed food and drink establishments, almost all (95%) of the dining room fl oors were constructed of tiles. The of the kitchens were clean (Table 3).

Factors infl uencing kitchen cleanness
Good premise fl oor status, availability of adequate light, running water and dustbin availability were found having signifi cant association with overall cleanliness of the kitchen.
A kitchens whose fl oor was in a good repair condition (well fi t and easily to be cleaned) were 18 times more likely to be clean compared to a kitchen whose fl oor was in a poor repair

Kitchen cleanliness by type of establishments
The highest proportion of unclean kitchen was hold by snack bars, in which 69.7% of the total participated snack bars had unclean kitchen, followed by Coffee/Juice shop (55.6%) and restaurants (50%). The lowest proportion of unclean k itchen was observed in hotels in which only 16.7% of the total participated hotels had unclean kitchen (Table 5).

Sanitary and lavatory facilities of the establishments
Out of the total establishments, about 70% have lacked running water during inspection, and there was discontinuation of water supply in majority (95%) of the establishments i.e. in 88.7% of them, piped water had been discontinued for more than three months.
Only 20.9% of the establishments were observed to use the conventional three compartments dish washing facility.
Additionally, in 23(16.5%) of the establishments there was no distance separating the dish/cup washing place from the latrine that is, they were adjacent to each other. Moreover, only about a third, 41(29.5%), of the establishments placed their sanitized utensils appropriately (dried, closed, and separated), and majority of the establishments (92.1%) were not observed to use hot water while washing dishes ( Table 6).  (Table 7).

Infestation of vermin
As indicated in Figure 2, more than one-third (37.4%) of the establishments were found to be infested by vermin.
The infesting vermin were either fl ies (55.8%), cockroaches (26.9%) rats (3.8%) and/or by more than one of the vermin (13.5%).  Establishments with unclean latrine were found more likely to be infested with vermin than those with clean latrine though no signifi cant statistical association was found in the multivariate logistic regression (Table 9).

Food handler's hygienic practices
Among the 139 assessed food and drinks catering establishments, food handlers with appropriate cover-coat and short trimmed and clean nail were found in 79.1% and 59.7% of the establishments. Likewise, food handlers whose hair was properly covered were observed in only 54.7% institutions. Surprisingly, in about 60% of the establishments', food handlers were observed wearing different kind of fi nger or hand ornament (Figure 3).

Situation of food storage and preservation
As described in Table 10, Majority (38.8%) of the establishments had complete separation of raw foods and other non-food materials, while 36.7% were found to separate the materials side by side (close to each other) and in the remaining 24.5% institutions the items were found mixed. About half (51.8%) of the establishments stored raw foods on the fl oor.
Majority (97.8%) of the establishments were found to have

Discussion
To reduce food borne illness related to poor hygiene practices, food hygiene procedures and practices in different food establishments should be improved [18]. The study revealed that, majority (91.4%) of the establishments'' dining room, about two-third (66.7%) of the kitchens and 68.5% of the store room had good and clean sanitary conditions. Safer food preparation and handling were reported by persons who were females, at least 40 years of age and at least having high school level education in some studies conducted elsewhere [19,20].Majority of the food handlers in our study were found      to be males, in the age range between 20 and 35 years and a few of them had reached higher educational level. The reason for more number of young males as food handlers' might be due to the higher unemployment rate in other sectors of the country. It is quite advisable that food establishments have separate premises for their different kinds of services. Luckily, the fi ndings of this study showed that a high percentage of the surveyed establishments had separate rooms for kitchen and other services. Besides, majority of the establishments had separate room for store. Similarly, the presence of separate rooms had facilitated good food handling process in a study conducted in Ethiopia [2]. Rooms where food is prepared, stored and served should be of impervious, smooth, and not having cracks or crevices. However, a proportion of the establishments' kitchens fl oor was cracked and not easy to clean. Likewise, the ceiling status of the kitchen and dining premises was seen to vary, the dining rooms were clean and smooth whereas the kitchens' were rough and dirty. This suggests that more focus is given to the maintenance and repairing of the dining rooms, to attract customers, than the kitchen premises. Moreover, about a third of the kitchens and store rooms were found unclean. It is apparent that sanitary inspections are very important tools in food and drink establishment services for regulating the cleanliness of the premises and preventing food borne diseases.
Studies have revealed that, the probability of having good food safety practice was higher among food handlers supervised by health professionals [16,21] Additionally, perishable and non-perishable food were found together in the same refrigerator in more than a third of the establishments, this procedure had signifi cantly increased the spoilage of food. It was fi tting to fi nd out that almost all of the food and drinks catering establishments had at least one refrigerator, but only a fi fth of them had fi xed thermometers with temperature readings ≤ 10 0 C. our fi ndings are in line with the study conducted in Australia [23], reporting unsafe food preparation practices in majority of the respondents leading to food borne illnesses knowledge of food handling, increased educational status and training of food handlers' had a direct association with good food handling practices in studies conducted in many countries [5,16,[24][25][26][27][28].The presence of well-maintained and proper food handling practices, such as wearing clean working garment, hair covering, and keeping fi ngernails short and clean have a benefi cial ultimate impact on serving safe food to consumers. Still, more than a third of the establishments' food handlers were not observed to appropriately cover their hair. Avoidance of wearing fi nger or hand ornament is also an essential prerequisite for a food handler as it is a potential cause of chemical and microbiological food poisoning, but the current study showed that about two-third of food handlers worn fi nger or hand ornament while serving or preparing food. Improvements of practices during food preparation, storage and cleaning practices, can be obtained through education and training of food handlers involved in preparation, processing and service of meals [29].

Limitations of the study
Limitations of the research stem from the use of descriptive observational study due to its inherent limitation to defi ne cause and effect relationship. No laboratory analysis was made for detecting microbial quality of food utensils. Assessing perceptions or satisfaction level of consumers about the services provided by the establishments might have enriched the fi ndings of the study. Since, the study was only done in a particular site of Asmara, generalization of the fi ndings to that of the country is not feasible. Hence, nationwide research is recommended to fi ll the abovementioned gaps and to deepen the factors behind the unhygienic practices. Moreover, given the great cultural differences within the country, more research is necessary to determine if similar results would be derived across the country. This study did not try to specify hypothesis regarding food hygiene profi le.

Conclusion
The sanitary condition of the food and drinks catering establishments in the study area was found to be poor. The