Ghaffari et al. BMC Public Health (2020) 20:401 https://doi.org/10.1186/s12889-020-08541-8 RESEARCH ARTICLE Open Access Effectiveness of a health intervention based on WHO food safety manual in Iran Mohtasham Ghaffari1, Yadollah Mehrabi2, Sakineh Rakhshanderou1, Ali Safari-Moradabadi3 and Seyyede Zenab Jafarian4* Abstract Background: Food safety manual was developed by the World Health Organization (WHO) to train professionals to reduce the burden of foodborne diseases as a global strategy. The present pioneering research aimed to explore the effectiveness of an intervention based on the manual of five keys to safer food by WHO in enhancing the knowledge, attitude and behavior of Iranian Female Community Health Volunteers (FCHVs). Methods: In the present quasi-experimental research, FCHVs (n = 125) were selected and assigned to two groups, an intervention and a control. A modified version of the questionnaire based on WHO manual was used to measure knowledge, attitude and behavior of the sample. The questionnaire was first completed at the outset of the study (pre- test) and then once again in 2 months of the intervention (post-test). Face and content validity of the questionnaire was tested and confirmed. Cronbach’s alpha was used to test the reliability of the questionnaire along with the test- retest method of testing reliability. The data entered SPSS16 for statistical analysis. To this aim, Chi-squared test, dependent and independent samples T-test, ANOVA and ANCOVA were run. Partial population attributable risks were calculated and corresponding 95% confidence intervals (95% CIs) were estimated using a bootstrap method. Results: The two groups showed no statistically significant difference in the pretest (p > .05). In the post-test, the mean scores for all variables was higher in the intervention group than the control, and this difference between the two research groups was statistically significant (p < .001). When the volunteers were adjusted for age and experience in healthcare centers, the mean scores were significantly higher in the intervention group than the control (p < .001). Conclusion: It was revealed in the present study that the educational intervention based on five keys to food safety manual by WHO managed to improve participants’ knowledge, attitude and behavior. Translation of the target guideline in future can be a great help to researchers in prospective research. Trial Registration: Retrospectively registered: Iranian Registry of Clinical Trials IRCT20160822029485N4, at 2020-03-16. Keywords: WHO food safety manual, Intervention, Knowledge, Attitude, Behavior, Health volunteer Background from diseases transmittable through food. This has turned The significance of maintaining human health and pre- into a global issue [1]. Diseases that can be transmitted venting diseases is known to all. Safe and healthy food is a through food point to the prevalence of public health is- key to prevention of diseases and protecting environment sues in developing and developed countries. Yet, health from germs. Annually, millions of people worldwide suffer and economy in the former suffer more from these issues [2]. Human health often works through food safety frame- * Correspondence: [email protected] works and is more focused on proper diet, high-quality 4School of Public Health and Safety, Shahid Beheshti University of Medical food and eating habits. Yet, it is noteworthy that socioeco- Sciences, Tehran, Iran nomic issues can affect all procedures of food preparation Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Ghaffari et al. BMC Public Health (2020) 20:401 Page 2 of 9 from production to consumption. Thus, it can promote or In the present research, FCHVs entered the study to damage individual and social health [3]. Food-related dis- learn the content proposed by WHO about food safety. eases are reported to prevail in food service providing Local women older than 25 years receiving an 18-day areas including restaurants, hospitals, schools, and so on training of different Primary Health Cares (PHC) con- [4]. Food safety is a complicated matter of concern. Des- cerns are called FCHvs. The training is concerned with pite quite many campaigns on food safety and educational mother and child health care matters, mainly [17]. These efforts along with decades of exploratory microbiology, women work part time, 5–6 h per week. This time may food-related diseases are the main source of human dis- change contingent upon the programs FCHVs take part eases [5]. Reports of disease outbreaks spanning from in. It seems that FCHVs are committed to volunteer be- 2006 to 2010 have shown an increase of about nine fold cause their retention rate is high (96%) [18]. The main [6]. The majority of outbreaks and cases of diseases have reasons for high motivation are social respect, religious been transmitted from contaminated food to human. and moral duty, in policy making perspective [19], these Health authorities’ behaviors and methods have increased volunteers have not had a voice in policy making yet. the rate of these diseases and can be related to particular Also, they have not received any payment for their activ- organisms [7]. Therefore, a high percentage of diseases is ities and offered services [20]. caused by improper preparation of food materials at home Local FCHV in Iran play a key role in primary health- [8]. Women produce between 60 and 80% of food mate- care provision and teaching the urban community. rials in many of the developing countries and account for These people are the first and foremost means of com- half of food products at a global scale [9]. munication between urban community and the health The growing number of diseases transmittable through network. They lie at the core of urban community and food has made all countries attempt extensively to im- always communicate with families. They play an effective prove food safety [10]. Some research revealed that peo- role in raising the knowledge of women and mothers ple’s higher knowledge tremendously affects their and changing their attitude. A body of related literature nutrition [11]. Some other research revealed a correl- has proved the role of FCHV in raising the knowledge of ation between food safety education and raising know- society under cover [21–24]. Thus, it can be a proper ledge of food service providers [12]. Moreover, copious target group to disseminate health-related information. educational interventions have been run to develop A review of the relate literature showed that no relevant ready-to-eat food. Yet, these interventions are only ef- research has been conducted, so far, in Iran in relation fective when they are evidence-based. WHO has recently to the five keys. Considering the key role of women in developed five keys to food safety [13]. food safety and the role of FCHVs in educating women, the present research aimed to explore the effectiveness Five keys to food safety promotion by WHO of a health intervention in the light of WHO five-keys in WHO emphasized health promotion and food safety, FCHVs’ knowledge, attitude and behavior. consulted food safety experts and consumers at risk for a year and proposed a five-step guideline to prevent Methods food-related diseases. At the core of the guideline there Research domain and population are five key points to consider: keeping clean, separating Damavand is a county in Tehran province and accommo- fresh from cooked food, full cooking, storing food at safe dates 125,480 residents. According to the latest national temperature and consume healthy drinking water and division reports, this county is divided into two districts, raw materials [14]. These five keys to safe food are of a the center and Rudehen. These two districts together con- great significance in developing countries. Those in- sist of 5 cities (Damavand, Rudehen, Absard, Abali and volved in food production in these countries can use this Kilan) and 111 villages. This county has got 5 healthcare information to affect the safety of food materials. This centers, 1 health station and 1 hospital affiliated with Sha- guideline has been translated in more than 40 languages hid Beheshti University of medical sciences. This county of the world and is currently used worldwide to convey was selected in this research due to its geographical loca- the healthy message sent by WHO [14]. Along with the tion, ethnic diversity, inclusion of urban and rural popula- 5-key to food safety poster, WHO has published a gen- tions together and ease of access and coordination of eral book of instructions which acts as a framework for team work from Shahid Beheshti University. teachers and other institutes interested in food safety to develop instructional materials and programs for those Research design, sample selection, inclusion/exclusion groups at risk [15].