Ethnic considerations along with language proficiency must be factored into foodservice hand hygiene training programs. All food handling staff must be aware that “Failure in hand hygiene systems is the number one contributing factor in foodservice outbreaks.” according to Jim Mann, executive director of the Handwashing For Life Institute. Dr. D. Pettit of the World Health Organization (WHO) reflects a supporting view in his healthcare work where he considers hand hygiene as the most effective tool in preventing cross-contamination and lowering HAI, hospital acquired infections.
Within the foodservice industry, public health officials, lead by the Centers for Disease Control and Prevention, agree that regular handwashing is the most effective defense against the spread of foodborne illness. It is the responsibility of foodservice management to offer effective hand hygiene facilities complete with best practice protocols, products and training in order to keep their customers and workforce safe
Handwashing training involves not only education, but also behavior modification and constant reinforcement. Training is challenging even with a receptive group of trainees, however, adding the extra obstacle of differing cultural and religious attitudes into the mix, makes influencing attitudes and changing behaviors an even tougher task.
According to a 2008 study conducted by the WHO, hand hygiene is strongly influenced by religious faith and potentially affects compliance. Although this and other published studies focused on healthcare settings, one can assume that religion and culture influences hand hygiene in the foodservice sector in a similar fashion. With a growing influx of immigrants from India, Pakistan and the Middle East, Muslim religious and cultural traditions must be taken into consideration when formulating best practices in hand hygiene within the foodservice industry.
Islam places great emphasis on physical and spiritual cleanliness. The Qu’ran offers specific instruction on when and how hand cleansing should occur. These include before prayer (5 times a day), before and after meals, after using the toilet, after touching a dog, shoes or cadaver, and after handling anything soiled. Compared to most other religions, these rules are quite specific and stringent. More importantly, these rules are followed by the majority of Muslims, not just those who consider themselves ardent followers or overtly religious. One reason for such compliance is that hand hygiene patterns are usually established within the first 10 years of life and become ingrained behavior. With such specific instructions from the Qu’ran and a high rate of compliance, one would assume hand cleanliness among Muslim workers within the healthcare and foodservice setting would not be an issue. However, although Islam teaches its followers that cleanliness is vitally important, other Muslim practices may increase the risk of cross contamination and illness transmission.
A common popular belief in the Muslim (and Hindu, Jewish and African) culture is that the left hand is considered unclean as it is used for hygienic cleaning, while the right hand is used for eating. Although toilet paper is widely accepted and used, culture dictates that Muslims should clean their private parts after bathroom use with their bare left hand. This practice is obviously problematic, as even vigorous post-bathroom hand washing often doesn’t remove all potentially illness-causing pathogens. Additionally, many Muslims don’t like to use utensils to eat and prefer to use their bare hands. Again, although the Qu’ran instructs individuals to wash before and after eating, it is almost impossible to wash away all risk. Perhaps the greatest obstacle foodservice and healthcare management may face when trying to ensure compliance with hand hygiene standards within the Muslim workforce, is their reluctance, and often refusal, to use the gold standard in convenient hand disinfection - alcohol based hand sanitizers.
Alcohol hand sanitizers are considered an adjunct to handwashing and are increasingly used in both foodservice and healthcare to maintain hand cleanliness standards between wash cycles. Using hand sanitizer without a preceding handwash, preferably with a nailbrush, is totally unacceptable after defecation or any use of the restroom.
Although the Qu’ran specifically forbids the use of alcohol, it permits the use of any manmade substance to reduce illness or contribute to improved health, including alcohol used for disinfection. In fact, the Muslim Judicial Council of South Africa has issued written permission regarding the use of alcohol not produced as a result of fermentation for the specific purpose of disinfecting the hands. In addition, due various health concerns during Hajj (religious pilgrimages to Mecca and Medina), in 2002 the World Muslim League in Mecca issued a fatwa allowing the use of alcohol based hand sanitizers. During this year’s Hajj, Saudi Deputy Health Minister Dr. Ziad Memish reiterated that Saudi senior religious leaders deem alcohol-based sanitizers acceptable. Despite these fatwas and their documented approval of alcohol based hand sanitizers, many Muslims still adhere to their conservative beliefs that all alcohol is unacceptable. Not only is the smell of alcohol on the skin disturbing, some fear that the alcohol in the sanitizers may be inhaled or absorbed into the skin causing intoxication.
According to Mohammed Nazir, Chairman of the European Halal Development Agency, the reluctance to utilize alcohol based hand sanitizers and western toilet practices is not an issue limited to new immigrants. Whether new to western culture, totally accustomed to western ways, or even born and raised in the West, 60 to 70 percent of all Muslims, strictly practicing or not, will still eat Halal, fast, attend Friday prayers and abstain from all alcohol related products.
When experiencing an increasing Muslim population, it is the responsibility of foodservice providers to strike a balance between accommodating various cultures and ensuring the health and welfare of consumers and staff. Although this task sounds daunting, there are several ways to encourage hand hygiene compliance among Muslim workers, in addition to regular and comprehensive hand hygiene training.
- Acknowledge and incorporate Muslim beliefs and teachings into hand hygiene training.
- Point out that religious leaders in many countries have issued fatwas allowing alcohol based hand sanitizers. Contact state or local Muslim religious leaders for assistance and advice.
- Explain that studies have shown that the absorption of alcohol during the use of alcohol-based hand sanitizers is minimal and far below levels of intoxication.
- Utilize the term antiseptic instead of alcohol during hand hygiene training.
- Use hand sanitizers with a lower alcohol odor, usually ethyl alcohol rather than isopropanol. (Alcohol is the only germ-killing ingredient accepted in the FDA’s Model Food Code.)
- Note: A fatwa recently released in Europe states that alcohol based hand sanitizers are acceptable if a comparable non-alcohol based sanitizer is not available. Recent European formulations using active ingredients other than alcohol may affect the future of this fatwa in Europe.
- Encourage the use of a nailbrush after restroom visits.
More research and study needs to be conducted into the effects of cultural and religious beliefs on hand hygiene in the foodservice industry. A little knowledge, understanding and inclusion of these beliefs in hand hygiene training can lower the risk of pathogen transmission and may decrease the spread of foodborne illness.
- Karaan, Yusuf. "To Sister Asa Barendse." May 21, 2009. Athlone, Republic of South Africa: Muslim Judicial council (S.A.), Print 34.
- Mann, Jim. "Conference for Food Protection." handwashingforlife.com. 15 August 2009. handwashingforlife, Web. 4 Jan 2010. <http://www.handwashingforlife.com/conference_food_protection>
- Mann, Jim. "Handwashing: 5 Steps to a Best-Practice Payoff." Food Safety Magazine October/November 2005:n. pag. Web. 4 January 2010 <http://www.handwashingforlife.com /handwashing_5_steps_to_a_best_practice_pay_off>
- Nazir, Mohammed. Telephone Interview by Zvia Shever. 17 December 2009.
- Pittet, D. "Religion and Culture: Potential undercurrents influencing hand hygiene promotion in health care." American Journal of Infection Control. 37.1 (2009): 28-
- Sacirbey, Omar. "Will flu epidemic slow the Hajj?." stltoday.com 17 December 2009: n. pag. Web. 3 Jan 2010.