915689

research-article2020
EHI0010.1177/1178630220915689Environmental Health InsightsGirmay et al

Determinants of Sanitation and Hygiene Status Among Environmental Health Insights

Volume 14: 1–9

Food Establishments in Addis Ababa, Ethiopia © The Author(s) 2020

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Aderajew Mekonnen Girmay1 , Sirak Robele Gari1, DOI: 10.1177/1178630220915689
https://doi.org/10.1177/1178630220915689

Bezatu Mengistie Alemu2, Martin R Evans3

and Azage Gebreyohannes Gebremariam1
1Ethiopian Institute of Water Resources (EIWR), Addis Ababa University, Addis Ababa, Ethiopia.
2 College of Health and Medical Sciences, Haramaya University, Haramaya, Ethiopia.
3 Microbiology Consultant and Laboratory Director, New York, NY, USA.

ABSTRACT

Introduction: Despite advancements in food science and technology, foodborne disease remains one of the major public health prob-
lems. Poor sanitation and hygiene conditions of food establishments are the major causes for the occurrence of foodborne disease. There-
fore, this study aimed to investigate core determinants of sanitation and hygiene status among food establishments.

Methods: Institution-based cross-sectional study design was conducted in Addis Ababa city. A stratified random sampling technique was
deployed to select 413 study participants. Data were collected through interview and using observational checklist. Sample size was deter-
mined by using a single population proportion formula. To analyze the data, binary logistic regression and multivariable logistic regression
analysis was conducted. In all analysis, P-value less than .05 were considered statistically significant.

Results: The study revealed that 57.4% of the food establishments were under poor sanitation status. In the multivariable analysis, pres-
ence of trained managers on hygiene and sanitation (adjusted odds ratio [AOR] = 6.10 with 95% confidence interval [CI]: 2.41-15.45), pres-
ence of renewed licenses (AOR = 3.07 with 95% CI: 1.18-7.99), absence of bureaucratic function to obtain permission to renew the food
establishment buildings (AOR = 2.43 with 95% CI: 1.25-4.70), and presence of at least 10-m distance between toilet and kitchen (AOR = 9.19,
at 95% CI: 5.63-15.02) were associated significantly with sanitation and hygiene status.

Conclusions: Above average of the food establishments were found to be in poor sanitation and hygiene state. Many core determinant
factors that influence sanitation and hygienic status of food establishments were identified. The researchers suggest that formal training on
sanitation and hygiene for managers of food establishments should be provided to reduce the occurrence of foodborne diseases. Moreover,
strong food and water safety policy and strategy should be promulgated to improve sanitation and hygiene status of food establishments.

Keywords: Sanitation, hygiene, food establishment, determinant factor, Addis Ababa

RECEIVED: December 26, 2019. ACCEPTED: February 28, 2020. Declaration of conflicting interests: The author(s) declared no potential
conflicts of interest with respect to the research, authorship, and/or publication of this
Type: Original Research article.

Funding: The author(s) disclosed receipt of the following financial support for the CORRESPONDING AUTHOR: Aderajew Mekonnen Girmay, Ethiopian Institute of Water
research, authorship, and/or publication of this article: Ethiopian Institute of Water Resources (EIWR), Addis Ababa University, P. O. Box 81134, AAiT Campus, Addis Ababa,
Resources, Addis Ababa University was the funder to this study. The funders had no role in Ethiopia. Email: [email protected]
study design, data collection, analysis, decision to publish, and interpretation of the data or
preparation of the manuscript for publication.

Introduction caused an estimated 1.3 million deaths and are the fourth lead-
Foodborne disease remains a major public health problem ing cause of years of life lost in developing countries.15 Between
worldwide.1-4 Specially, it is more severe in low-income coun- 1998 and 2004, an average of 9040 foodborne and waterborne
tries due to poor sanitation, insufficient food safety laws, and disease outbreaks were reported to the Centers for Disease
weak regulatory systems.5,6 The African and the South-East Control and Prevention and approximately 4675 (52%) of these
Asia Regions have the highest foodborne incidence and highest were attributed to food establishments.16 Rapid urbanization
death rates.7 Specifically, due to poor water quality and inade- and changes in lifestyle led people to eat outside of their house
quate sanitation facilities, the Sub-Saharan Africa countries frequently and it causes to foster many food establishments
have been a great burden of foodborne and waterborne illness.8-10 which characterized with poor sanitation status like unhygienic
Adequate sanitation, together with good hygiene and safe water, kitchen, poor accessibility of water supply, and poor practice of
is fundamental to good health and to social and economic devel- liquid and solid wastes management.17 However, each food
opment.11 That is why many scholars said “sanitation is more establishment which supplies food for a large number of
important than independence.”12 However, the World Health customers has the responsibility to maintain the safety and
Organization estimated that in developing countries up to 2 wholesomeness of food items although still foodborne disease
million deaths are estimated per year which aggravated due to outbreaks arise from food establishments. Although the federal
poor sanitation and hygiene practices.13 In Africa, it is estimated government of Ethiopia launched food and water safety pack-
that 92 million people fall ill from consuming contaminated ages at the capital city, Addis Ababa in 2009, still the city has
foods, resulting in 137 000 deaths each year.14 Diarrheal diseases recurrent foodborne and waterborne outbreaks.18

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2 Environmental Health Insights 

A large number of food establishments were found in Addis

Ababa. Most of the food establishments have been subjected to
poor sanitation and hygiene practice. As a result, recurrent
foodborne and waterborne outbreaks especially diarrheal dis-
eases including acute watery diarrhea have occurred and many
users of the food establishments are exposed to many health
problems. Therefore, this study aimed to assess determinants of
sanitation and hygienic condition among food establishments
to improve the community health. Furthermore, the finding of
this study might assist to make sound decisions that target
tackling the health problems of the food establishment cus-
tomers and residents of the city. This study also has a signifi-
cant input in the formulation of appropriate strategy for
program planning and evaluation to improve the sanitation
status. In conclusion, this study has an important contribution
to solving community health problems arising from poor sani-
tation and hygiene practice of food establishments. Furthermore,
the new results of this study may also be used by policy makers
and other concerned bodies as a reference, on which to base
decisions.

Methods
Description of the study area
The study was conducted in Addis Ababa city. According to
the 2017 report of Addis Ababa Food, Medicine and Health
Figure 1. Map of Addis Ababa city administration.
Care Administration and Control Authority (AAFMHACA), Source: Girmay et al.19
there are 1141 licensed food establishments in the city. The
location map of the Addis Ababa city is depicted in Figure 1.
the non-response rate, 10% contingency was also considered.
Accordingly, the required sample size was 420.
Study design
(Z 2 ) × P(1- P)
An institutional-based cross-sectional study was conducted n=
d2
among food establishments of Addis Ababa city administra-
where n is the calculated sample size, z is the standard score
tion from July to August 2019 to assess determinants of sanita-
corresponding to 95% confidence interval (CI), P is the
tion and hygiene status.
assumed poor sanitary status of the food establishments
(46.2%), and d is the marginal error (5%). Then,
Study population
n = (1.96)2 × (0.5)2
, n = 382 + 38 = 420 Therefore, the sample
All selected food establishments located in Addis Ababa city (0.05)2
administration. size (n) for this study was = 420.

Inclusion criteria Sampling procedure

All food establishments that have been provided service for at The study participants were selected using a stratified, sim-
least 6 months in the city was the inclusion criteria. ple random sampling technique. To collect data, a listing of
the 1141 the licensed food establishments was obtained
from AAFMHACA. These 1141 food establishments were
Sample size determination
stratified into slum and non-slum areas based on their loca-
The sample size was calculated using a single population pro- tion. Sample allocation was conducted in the slum and non-
portion formula (EPI INFO version 7.2.2.6); with the assump- slum areas in addition to the large and small food
tion of 46.2% proportion (P) of food establishments used establishments. After the food establishments were strati-
hygienic practices observed in kitchen (wash utensils using hot fied based on their location and size (large or small), the
water),16 acceptable margin of error 0.05 (d), and with 95% required sample was selected at random. Based on this, 170
confidence level (Z α/2), the sample size will be calculated. For and 250 samples of food establishments were taken from the
Girmay et al 3

Figure 2. Systematic structure of the study sampling procedure.

non-slum and slum areas, respectively. From the non-slum Data quality assurance
area (170), 23 samples from the large and 147 samples from
A questionnaire was prepared in English and translated into
the small food establishments were collected. Besides, from
Amharic and back to English to keep the consistency of ques-
the slum area (250), 10 samples from the large and 240 sam-
tions. The quality of data was ensured through training of data
ples from the small food establishments were collected.
collectors, close supervision, prompt feedback, and daily
Finally, using a simple random sampling technique, 420
recheck of completed questionnaire.
food establishments were selected to assess sanitation and
hygiene status. A stratified random sampling technique was
used in both slum and non-slum areas as well as large and Data analysis
small food establishments of Addis Ababa. The main pur- All data were checked for correctness of information and code.
pose of stratification was to ensure representativeness for Data analyses were performed by using SPSS (Statistical
food establishments. In summary, the sampling procedure Package for the Social Sciences) software version 20. Descriptive
for this study is depicted in Figure 2. statistics such as frequency for categorical and mean and
standard deviation for numerical data were used. Moreover, to
Data collection procedures analyze the data, binary logistic regression and multivariable
logistic regression analysis was conducted. In all analysis,
Data enumerators were identified based on professional capa- P-value less than .05 was considered statistically significant.
bility and technical experience in collecting the required data.
Accordingly, 15 health professionals with Bachelor of Science
Operational definitions of key terms
with extensive experience in a similar data collection practices
were employed. In addition, 4 Master’s degree holders who Sanitation and hygiene status is the outcome variable of
acted as supervisors were recruited for supervision of data col- this study, which was computed by taking summation of
lection. Two-day training was given to the data collectors and 24 criteria, indicated in Table 2. Each criterion was given
supervisors. After written consent was obtained from each a value of 1 for the presence of sanitary condition or cor-
food establishment managers, the data were collected using rect response and 0 for the absence or incorrect response.
observational checklist and through face-to-face interview The sum of these conditions was calculated and the mean
using structured questionnaire adopted from similar literatures. score of all observations and interview questions was used
Furthermore, a meter was used to measure horizontal distance as a cut-off point to categorize establishments as good or
between toilet and kitchen. poor sanitation status. Food establishments with equal to
4 Environmental Health Insights 

or higher than mean value (⩾16.8) were categorized under Then, data were collected after assuring the confidential nature
good sanitation and hygiene status, whereas food establish- of responses.
ments which score below mean (<16.8) were considered as
poor sanitary conditions. Results
Food establishments: means institutions that provide food Socio-demographic characteristics of food
establishment managers
and drinks for selling to customers.
The study assessed a total of 413 licensed food establishments,
Large food establishment: hotels with one or more stars.
which includes 7.7% hotels with one or more stars, 13.3% non-
Small food establishment: small vendors, non-star hotels, bars, star hotels, 27.1% bar and restaurants, 7% cafe and restaurants,
restaurants, cafes. 38% restaurants, 2.2% groceries, and 4.6% cafe and others.
However, only 28.1% of the food establishments had renewed
Slum area: area with poorer sanitation infrastructure.
license. Of the total observed food establishments, 92.3% of
Non-slum area: area with better sanitation infrastructure. these were small food establishments. The mean year of service
of the food establishments was 6.98 years ranges from 1 to
Adequate ventilation: refers to food establishments feeding
22 years. Out of the 420 managers representing those food
room which had windows that can be approximately 10%
establishments, 413 participated in the study with a response
of its floor.
rate of 98.33%. From the total participated managers of the
AOR: adjusted odds ratio. food establishments, 62.5% of them were male. Two thirds of
the managers, 66.3%, were found to be above 39 years. The age
COR: crude odds ratio.
of participants representing the food establishments ranges
from 21 to 78 years, with a mean age of 45.2 years. Nearly all
Study variables (94.9%) of the food establishment managers were found to
Independent or explanatory variables. The predictor variables have ability at least reading and writing. However, only 31.2%
of this study were distance between toilet and kitchen, source and 32.7% of the food establishment managers and food han-
of water supply, functional shower, functional refrigerator, dlers took training about sanitation and hygiene in the past
functional toilet, functional hand-washing, renewed license, 1 year, respectively. Furthermore, only 27.6% of the managers
regulatory inspection, 3 dishwashing systems, separate owned the food establishment building (Table 1).
kitchen, water storage, utensil cleanliness, bureaucratic func-
tion to obtain permission from the authorized body to renew Sanitation and hygiene status of food establishments
the food establishment buildings, food handlers having
health examination certificate, liquid and solid waste man- In this study, the researchers assessed the overall sanitation and
agement practice, etc. hygiene condition of the food establishments. The percentage
mean score of availability of sanitation and hygiene facility
Dependent or outcome or response variables. Outcome of this questions was found to be 70.1% ± 20.19%. Moreover, the
study was sanitation and hygiene status. mean of correct answer questions to sanitation and hygiene sta-
tus of food establishments was found to be 16.8. However,
based on the cut-off point, only 42.6% of food establishments
Ethical consideration
had good sanitation and hygiene status. Above three fourths
First, a letter of support was obtained from the Ethiopian (83.3%) of managers of the food establishments faced bureau-
Institution of Water Resources, Addis Ababa University. Then, cratic function to obtain permission from the authorized body
ethical approval was obtained from the Ethiopian Public to renew the food establishment buildings. Most of the food
Health Institute Scientific and Ethical Review Board with ref- establishments’ (98.1%) source of drinking water was munici-
erence number EPHI 613/138 in June 2019. To collect the pality. Furthermore, 91% of the food establishments had private
data, written consent was obtained from each respondent piped water. However, only 28.3% of the food establishments
after the objectives of this particular study were explained. received continuous piped drinking water supply. 90.8% of
Candidates were informed that their participation was volun- those had disinfectants for washing water storage equipment.
tary. Confidentiality and privacy of respondents were ensured Two thirds (65.6%) of the food establishments had 3 dishwash-
throughout the research process. The study design did not ing systems which assisted to reduce contamination and food-
harm those taking part and it did not include any identifying borne disease. However, only 38.4% of the food establishments
information like name or address of respondents and establish- had a functional shower facility. Nearly all (93.7%) and above
ments. They were well informed by the data collectors that the three fourths (77.7%) of the food establishments had a func-
study was only for the purpose of academic and institutional tional toilet and a functional refrigerator, respectively. Moreover,
research and not for any other business or illegal activities. 87.2% and 93.5% of the food establishments had a functional
Girmay et al 5

Table 1. Socio-demographic characteristics of food establishment managers (n = 413).

Study variables Category Frequency % Mean Standard

deviation

Sex of managers Male 258 62.5

Female 155 37.5

Age group of managers <25 y 11 2.7 45.3 11.34

25-29 y 14 3.4

30-34 y 53 12.8

35-39 y 61 14.8

>39 y 274 66.3

Educational status of managers Illiterate 21 5.1

At least read and write 392 94.9

Trained managers about hygiene Yes 129 31.2

and sanitation in the past 1 year

No 284 68.8

Trained food handlers about hygiene Yes 135 32.7

and sanitation in the past 1 year

No 278 67.3

Ownership of food establishment Private 114 27.6

building

Rent 299 72.4

Service year of food establishments <5 y 165 40.0 8.26 16.043

5-9 y 155 37.5

10-14 y 58 14.0

15-19 y 23 5.6

>19 y 12 2.9

Renewed license by authorized body Yes 116 28.1

No 297 71.9

Type of food establishment One star and above 32 7.7

managers owned hotels

Non-star hotels 55 13.3

Bar and restaurant 112 27.1

Cafe and restaurant 29 7.0

Restaurant 157 38.0

Grocery 9 2.2

Cafe and others 19 4.6

Type of food establishments Small 381 92.3

Large 32 7.7

hand washing facility near the toilet and a separated kitchen, washing in the kitchen. In addition, 48.4% of the food estab-
respectively. Meanwhile, 45.8% of the food establishments had lishments did not have at least 10 m horizontal distance between
no running tap water for food preparation and equipment toilet and kitchen.
6 Environmental Health Insights 

Table 2. Availability of sanitation and hygiene facilities among food establishments (n = 413).

S. no. Criteria for sanitation and hygiene status of food establishments Answers % (n)

Present Absent

1. Absence of bureaucratic function to obtain permission from authorized body to renew food 16.7 (69) 83.3 (344)
establishment buildings

2. Source of the drinking from municipality 98.1 (405) 1.9 (8)

3. Private piped water in food establishments 91 (376) 9 (37)

4. Continuous piped drinking water supply in food establishments 28.3 (117) 71.7 (296)

5. Disinfectants for washing water storage equipment in food establishments 90.8 (375) 9.2 (38)

6. Three dishwashing systems in food establishments 65.6 (271) 34.4 (142)

7. Functional shower facility in food establishments 38.7 (160) 61.3 (253)

8. Functional refrigerator in food establishments 77.7 (321) 22.3 (92)

9. Functional toilet in food establishments 93.7 (387) 6.3 (26)

10. Functional hand-washing facility near toilet in food establishments 87.2 (360) 12.8 (53)

11. Soap near hand washing facility in food establishments 72.6 (300) 27.4 (113)

12. Separate kitchen in the food establishments 93.5 (386) 6.5 (27)

13. Running tap water for food preparation and equipment washing in kitchen 45.8 (189) 54.2 (224)

14. At least 10-m distance between toilet and kitchen 51.6 (213) 48.4 (200)

15. Inspection by regulatory body at least within a month 83.8 (346) 16.2 (67)

16. Septic tank for liquid waste 79.2 (327) 20.8 (86)

17. Presence of temporary solid waste storage containers in the food establishments 97.8 (404) 2.2 (9)

18. Solid wastes taken from the food establishments containers within 7 days 85.5 (353) 14.5 (60)

19. Practice of segregation of combustible and non-combustible solid wastes 66.1 (273) 33.9 (140)

20. Food handlers having health examination certificate at least within the past 3 months 78.9 (326) 21.1 (87)

21. Personal protective devices during the time of this questionnaire filled (white gown, hair protective cloth) 65.4 (270) 34.6 (143)

22. Dressing room to food handlers 38.3 (158) 61.7 (255)

23. Storage room for non-perishable foods 66.1 (273) 33.9 (140)

24. Adequate ventilation 69.7 (288) 30.3 (125)

Percentages mean score of correct answer to availability of sanitation and hygiene facilities 70.1% ± 20.19%

Of the assessed food establishments, 83.8%, 79.2%, and Determinants of hygiene and sanitation status
97.8% had an inspection by regulatory body at least within a among food establishments
month, a septic tank for liquid waste, and a temporary solid
In the binary logistic regression analysis, 6 predictor varia-
waste storage containers/receptacles, respectively. Furthermore,
bles—educational status of managers, presence of trained man-
66.1% of the food establishments had practice of segregation of
agers about sanitation and hygiene, presence of trained food
combustible and non-combustible solid wastes. Although
handlers, presence of renewed license, absence of bureaucratic
65.4% of the food handlers had personal protective devices like
function to obtain permission from the authorized body to
white gown and hair protective cloth, only 21.1% of the food
renew the food establishment buildings, and presence of at
handlers had health examination certificate at least within the
least 10-m horizontal distance between toilet and kitchen—
past 3 months prior to the study. Moreover, only 38.3% of the
were significantly associated (P-value < .028 at 95% CI) with
food handlers had a dressing room. From the observed food
sanitation and hygiene status of the food establishments. To
establishments, 66.1% and 69.7% of these had storage room for
control confounders, the 6 significant explanatory variables
non-perishable food items and adequate ventilation, respec-
were fitted to the condensed model of multivariable analysis.
tively (Table 2).
Girmay et al 7

Table 3. Multivariable logistic regression analysis of determinants of sanitation and hygiene status among food establishments (n = 413).

Study variables Sanitation status COR with 95% CI AOR with 95% CI

Good Poor

Trained managers about sanitation and Yes 76 53 2.64 (1.72-4.04) 6.10 (2.41-15.45)
hygiene in the past 1 year

No 100 184 1.00 1.00

Renewed license by authorized body Yes 67 49 2.36 (1.52-3.65) 3.07 (1.18-7.99)

No 109 188 1.00 1.00

Absence of bureaucratic to obtain Yes 157 187 1.00 1.00

permission to renew the food establishments

No 19 50 2.21 (1.25-3.90) 2.43 (1.25-4.70)

At least 10-m distance between toilet and Present 139 74 8.28 (5.25-13.04) 9.19 (5.63-15.02)
kitchen

Absent 37 163 1.00 1.00

Abbreviations: AOR, adjusted odds ratio; COR, crude odds ratio.

However, in the multivariable analysis, only 4 explanatory vari- food establishment buildings, absence of continuous piped
ables—including presence of trained managers, presence of drinking water supply, absence of functional shower facility,
renewed licenses, absence of bureaucratic to obtain permission and poor liquid and solid waste management practice.
to renew the food establishments, and presence of at least 10-m Especially, absence of continuous piped drinking water supply
horizontal distance between toilet and kitchen—were signifi- could be the leading cause to poor sanitation and hygiene sta-
cantly associated (P-value < .022 at 95% CI) with sanitation tus. Moreover, it might be a main factor to foster foodborne
and hygiene status. The final condensed model of multivariable disease in the city.
analysis was conducted to identify the explanatory variables of The finding of this study is lower than a study conducted in
sanitary condition of the food establishments. Accordingly, Bahirdar town where 78.7% of food establishments had poor
food establishments which owned trained managers about san- sanitation and hygiene status.20 However, the findings of this
itation and hygiene were 6.10 times more likely to be in good study is higher than a study conducted in the Mekelle town,
sanitation and hygienic condition when compared to food Tigray, north Ethiopia where only 17.1% of the food establish-
establishments that did not have trained managers (AOR = 6.10, ments had good sanitary status.21 This difference might be due
with 95% CI: 2.41-15.45). Furthermore, food establishments to the rapid development and urbanization in the capital city in
which have renewed license by authorized body were 3.07 addition to socio-economic status of the research areas.
times more likely to be in good sanitation and hygiene condi- In this study, presence of trained food establishment man-
tion than those which have not renewed their license agers on sanitation and hygiene, presence of renewed license,
(AOR = 3.07 with 95% CI: 1.18-7.99). On the other hand, absence of bureaucratic of housing regulation law to renew the
food establishments which had not faced bureaucratic function food establishments, and presence of at least 10-m horizontal
to obtain permission from the authorized body for renewal of distance between toilet and kitchen were the predictor varia-
the food establishment buildings were 2.43 times more likely bles significantly associated (P-value < .028 at 95% CI) with
to be in good sanitation and hygiene condition than those sanitation and hygiene status. The finding of the study indi-
which had faced bureaucratic function (AOR = 2.43 with 95% cated that the proportion of food establishments which had a
CI: 1.25-4.70). Besides, food establishments which had at least renewed formal license certificate was 28.1%. The main reason
10-m horizontal distance between toilet and kitchen were 9.19 could be due to ineffective effort of authorized health inspec-
times more likely to be in good sanitary condition compared to tors (concerned regulatory bodies) and absence of strong law
those which had not (AOR = 9.19 with 95% CI: 5.63-15.02) and rule of the trade and industry of the city. Moreover, invol-
(Table 3). untariness of food establishment managers to renew their
license might be a second factor. However, the observed food
Discussion establishments which renewed their license certificate have
The findings of the study revealed that above half (57.4%) of improved sanitation status compared to these which had not
the food establishments were in a condition of poor sanitation renewed their license.
and hygiene status. The major reasons might be the presence of The finding revealed that only 31.2% and 32.7% of the food
bureaucratic function from the authorized body to renew the establishment managers and food handlers took training about
8 Environmental Health Insights 

sanitation and hygiene in the past 1 year, respectively. Although 9.19 times more likely to have good sanitation and hygienic
presence of trained food handlers and managers can reduce condition than the odds of those with 10 m or less (AOR = 9.19,
foodborne disease and enhanced sanitation and hygiene practice at 95% CI: 5.63-15.02). This indicates that distance between
of food establishments,22 the result of this study indicated that a toilet and kitchen might be a core determinant factor that
significant number of food handlers and managers had not influences sanitation and hygiene of food establishments.
received training. This indicated that there is a gap in creation of Moreover, adequate distance between toilet and kitchen can
awareness and attention provision by the Government and con- prevent cross contamination and reduced foodborne disease.
cerned bodies to combat foodborne disease.
Furthermore, the finding of this study revealed that food Conclusions
establishments with managers who took training on sanitation Above average of the food establishments were found to be in
and hygiene were 6.10 times more likely to have good sanitation poor sanitation and hygiene state. Assessing sanitation and
and hygiene status when compared to their counter parts hygiene status of food establishments is an important activity
(AOR = 6.10 with 95% CI: 2.41-15.45). Many studies indicated to curbed foodborne diseases. In the finding, presence of
that knowledge and training of managers and staffs on sanita- trained managers, presence of renewed licenses, absence of
tion and hygiene have a direct relationship on the overall sanita- bureaucratic function to obtain permission from the author-
tion and hygiene improvement of food establishments.23,24 This ized body to renew the food establishment buildings, presence
revealed that gaining knowledge through training had a positive of at least 10-m horizontal distance between toilet and kitchen,
effect on ensuring sanitation and hygienic condition of food absence of continuous piped drinking water supply, absence of
establishments and food safety practices thereby reducing food- functional shower facility, and poor liquid and solid waste man-
borne illness. This is supported by a study conducted by Hedberg agement practice were the main determinant factors that influ-
et al25 which stated that managers who took food hygiene and ence the sanitation and hygienic status of food establishments.
sanitation training were associated with a reduced risk for food- The study introduces core determinants useful for increasing
borne illness. Moreover, different studies showed that managers’ community awareness, financing in the water sanitation and
knowledge and training about hygiene and sanitation have a hygiene (WaSH) sector as well as enhancing the capacity train-
direct influence on the sanitation and hygiene condition of food ing programs in water sanitation and hygiene (WaSH), moni-
establishments. They play a paramount role by ensuring availa- toring, evaluation and learning (MEL) system among the food
bility and cleanliness of sanitary facilities, proper waste manage- establishments, which have a paramount importance for the
ment, and food safety practices.20,26 sustainability of the sector.
In this study, the odds of food establishments which have
renewed license were 3.07 times more likely to have good sani- Recommendation
tation and hygiene status than the odds of those which had not The researchers suggest that formal and informal training on
(AOR = 3.07 with 95% CI: 1.18-7.99). This could be due to the sanitation and hygiene for managers of food establishments
should be provided to reduce the occurrence of foodborne dis-
role of inspection by the regulatory body since food establish-
eases. Strong food and water safety policy and strategy should
ment license is renewed after conducting firm regulatory inspec-
be promulgated to improve sanitation status of food establish-
tion. However, opposite to this study, a study done in Adwa
ments. The Government should be allocating adequate and
town states that licensing had no significant association with
continuous water supply to the food establishments to upgrade
sanitary status.27 This might be due to the difference in the level
the sanitation and hygiene status, thereby enhancing the health
of awareness creation and economic status of the cities.
of the residents. Moreover, the mangers/owners of the food
The odds of food establishments which had not received
establishments should provide attention to fulfill hygienic
bureaucratic function to obtain permission from the author-
facilities. The researchers also suggest further study to explore
ized body to renew the food establishment buildings were 2.43
additional determinants of sanitation and hygiene status among
times more likely to have good sanitation and hygiene status
the food establishments in the study area.
than the odds of those which had obtained (AOR = 2.43 with
95% CI: 1.25-4.70). This indicated that, to renew the food Acknowledgements
establishment buildings, the presence of bureaucratic function The researchers would like to thank the Ethiopian Institute of
to obtain permission from the authorized body created an Water Resources, Addis Ababa University, for providing
influence on the sanitation and hygiene of the food establish- Financial Support. In addition, the authors like to express grati-
ments. However, suitable formal permission to renew the food tude to the data collectors, supervisors, and study participants.
establishments without bureaucratic could be a basic instru-
ment to improve the sanitation and hygiene status of the food Author Contributions
establishments although this needs additional studies. The AMG, SRG, BMA, MRE, and AGG contributed to concep-
study also revealed that the odds of food establishments with tualization, methodology, investigation, data curation, formal
more than 10 m distance between their toilet and kitchen were analysis, validation and visualization, writing-review, and
Girmay et al 9

editing and approving. AMG contributed to funding acquisi- h t t p s : // w w w.w h o . i n t /n e w s -r o o m /d e t a i l / 0 3 -1 2 -2 0 1 5 - w h o - s - fi r s t-

ever-global-estimates-of-foodborne-diseases-find-children-under-5-account-
tion and writing original draft. for-almost-one-third-of-deaths
14. Waithaka PN, Maingi JM, Nyamache AK. Physico-chemical and microbiologi-
ORCID iD cal analysis in treated, stored and drinking water in Nakuru North, Kenya. Int J
Microbiol Epidemiol Res. 2014;24:29-37.
Aderajew Mekonnen Girmay https://orcid.org/0000-0002- 15. Hodge J, Chang HH, Boisson S, Collin SM, Peletz R, Clasen T. Assessing the
7911-4152 association between thermotolerant coliforms in drinking water and diarrhea: an
analysis of individual–level data from multiple studies. Environ Health Perspect.
2016;124:1560-1567.
16. Boro P, Soyam VC, Anand T, Kishore J. Physical environment and hygiene sta-
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