Factors associated with sanitary conditions of food and drinking establishments in Addis Ababa, Ethiopia: cross-sectional study

Introduction Food borne illness has been a global challenge and it persisted as a major public health problem, which consumes significant amounts of health care resources, particularly in the developing world. Poor sanitary conditions of food and drinking establishments are the major cause for the occurrence of food borne illness. This study assessed sanitary conditions of food and drinking establishments in Arada sub-city, Addis Ababa, Ethiopia. Methods A cross-sectional study design with stratified simple random sampling technique was used. Data were collected from 587 licensed food and drinking establishments and their managers, using interviewer administered questionnaire and observation checklist. The data were entered using Epi info version 3.5.3 and analyzed using SPSS version 20. Binary and Multi-variable logistic regression analyses were conducted. Results The study showed 58.8% of food and drinking establishments were under poor sanitary conditions; only 16.5% of the establishments had a proper liquid waste disposal facility, and only 7.2% had a suitable dish washing facility. Availability of trained managers on hygiene and sanitation (AOR = 2.56, 95% CI: 1.66-3.94); inspection from the respective body (AOR = 4.41, 95% CI: 2.9-6.8) and the distance between kitchen and toilet (AOR = 1.8, 95% CI: 1.1-3.0) were associated factors which affected sanitary conditions. Conclusion A majority of the establishments had poor sanitary conditions; where an absence of sanitary facilities for waste management was major cause. Regulatory bodies should conduct regular inspection on the establishments to promote and ensure proper hygiene and sanitation practices.


Introduction
Food borne diseases have been an issue for all societies [1].
Increases in the incidence of food borne diseases, often associated with outbreaks, which end up with threatening global public health security [2,3]. The risk of epidemics has been observed in the era of globalization that is characterized by increased frequency of travels and eating outside of the home [4,5]. According to World Health Organization (WHO) estimates, 2 million people in developing countries die due to food borne diseases each year; whereas, 30% of people in developed countries have a medical condition from food borne diseases each year [6]. Like other developing countries, Ethiopia is affected by the increasing burden of food-borne diseases; major food safety concerns are caused by physical, chemical, and microbiological contaminants. A summary report on out-patient visits of the Ministry of Health, released in 2014, indicates annual incidence of food-borne illnesses ranged from 3.4% to 9.3%, the median being 5.8% [7]. Food borne diseases can be caused by different pathogenic organisms (e.g. bacteria or viruses) that have contaminated them at some part of the food chain, between farm and fork [8]. Chemical contamination of foodstuffs, including methyl mercury, lead, arsenic, dioxins and aflatoxins (among others) may cause acute and chronic health effects such as neuro-developmental disorders, cardiovascular disease, cancers and renal disease [6,8]. Despite the considerable burden of food borne diseases on health and socio-economic development, food safety interventions have remained at the least priority in developing regions [1]. According to various studies, poor knowledge and practice of hygiene and sanitation, lack of basic sanitary facilities/infrastructures in food service establishments, and negligence in safe food handling are major causes of poor sanitary conditions of food and drinking establishments [3,[9][10][11][12]. Hence, the current study is aimed to gain understanding of factors affecting sanitary conditions of food and drinking establishments. It will provide systematic information for policy makers and planners in designing interventions to improve the sanitary conditions of food and drinking establishments.

Methods
Study setting, and population: The study was conducted in Arada Sub-city, which is one of the 10 sub-city administrations in Addis Ababa. It has a total of 61,818 households inhabited by a population of 240,165. According to data obtained from the sub-city administration, there are 2,066 licensed food and drink establishments distributed in the 10 districts of Arada sub-city administration. These establishments include: Cafeterias, Hotels, Bars and Restaurants, Juice houses, and Pastries/Bakeries. All the food and drinking establishments, and their respective managers or owners were the source population from which the sample study subjects were selected.

Study design and sampling:
A cross-sectional survey design was applied to assess sanitary conditions of licensed food and drinking establishments and associated factors. The sample size was determined using single population proportion formula for finite population with 95% confidence level, 78.7% prevalence of poor sanitary condition in the study area [10] and 4% margin of error.
Adding 10% non-response rate, the final sample became 587. The study used stratified simple random sampling techniques; list of all establishments in the study area was used as sampling frame and to stratify establishments by type (i.e. hotels, bar and restaurants, cafeterias, juice houses and bakery/pastry). The total sample size was proportionally allocated for each stratum; and study participants were selected using simple random sampling technique.
Operational definitions of outcome variables: Outcome variable, which is overall sanitary conditions, was computed by taking summation of eighteen criteria presented in table 3. Each criterion was given a value of 1 for the presence of sanitary condition/facility and 0 for the absence. The sum of these conditions was computed and the mean score of all observations was used as a cut-off point to categorize establishments. Food and drinking establishments with higher than mean value were categorized under good sanitary conditions; whereas, whose score was < 11.2 were considered as poor sanitary conditions.

Measurement tools, data collection and data analysis: Data
were collected by environmental health professionals, using a structured pre-tested questionnaire and observation checklist adopted from related literatures. The observation checklist was designed to assess availability, utilization, cleanliness and maintenance status of sanitary facilities that are used for food preparation, cleaning, waste handling and disposal. The raw data was edited, cleaned and entered using Epi-Info version 3.5.3, then exported to SPSS version 20. Data was cleaned in SPSS by running frequencies and cross tabulations. Preliminary frequencies were run to identify missing variables. Binary logistic regression analysis was Page number not for citation purposes 3 done to see the association between the dependent and independent variables. Variables with p-value less than 0.25 were taken as candidates of multivariable logistic regression analysis, and Multi variable logistic regression was performed to see the relative effect of independent variables on the outcome. The binary and multivariable analysis results were presented using Odds ratio with 95% confidence interval, and P-value < 0.05 was considered statistically significant.

Ethical considerations: The study was approved by Addis
Continental Institute of Public health and Haramaya University ethical review committee. Verbal consent was also obtained from each respondent after explaining the purpose of the study.
Confidentiality and anonymity was maintained by avoiding personal identifiers.
From the total 587 participants representing those establishments, 380(64.7%) were male; and mean age of respondents was 36 with standard deviation of ± 11.351 years ( The study also showed establishments with more than 6 meters distance between their kitchen and toilet had better sanitary condition, as compared to those with 6 or less meter distance (AOR = 1.8, at 95% CI: 1.1-3.0). Moreover, establishments which don't use firewood as major source of energy for cocking had better sanitary condition relative to those using firewood (AOR= 2.0, at 95% CI: 1.3-3.0) ( Table 4).

Discussion
This study revealed that a greater proportion (58.8%) of food and drinking establishments were found to be in poor sanitary condition;  [14]. Frequent inspection visits of establishments, supplemented by education is an effective mechanism to improve and maintain sanitary conditions of food and drinking establishments [8,14]. This study has the following strength and weakness: due to its cross-sectional design the study shows sanitary conditions at the instant of data collection, which may vary with time and situations. On the other hand, conducting observation to assess sanitary conditions of the establishments will reduce respondent bias, and it can be considered as strength of the study.

Conclusion
This study concluded that a majority of the establishments were   The study also showed strong association between poor sanitary conditions and absence of inspection visit from regulatory bodies; this shows the need to conduct for frequent evaluation of establishments, to take corrective actions which will in turn improve sanitary conditions.