Knowledge, Attitude, and Practices toward Food Safety among Students in Bangladesh: A Cross-Sectional Study

Abstract


Introduction
Nowadays, Food safety is a major issue for consumers, food industries, and regulatory agencies worldwide due to growing concern about unsafe food.Unsafe food causes foodborne illnesses or food poisoning and malnutrition, endangering everyone.Particularly infants, young children, pregnant women, the elderly, and immunocompromised individuals are likely to get foodborne diseases (FIVE KEYS TO SAFER FOOD MANUAL,WHO).Unsafe food also impedes socio-economic development and affects national and global economies, tourism, and trade (Food Safety fact sheet, WHO).Foodborne diseases or food poisoning, a rising public health problem, are accountable for considerable morbidity and mortality worldwide (Hassan & Dimassi, 2014a;Luo et al., 2019a).According to the World Health Organization (WHO), more than 200 diseases -ranging from diarrhea to cancers have been caused due to unsafe food containing harmful bacteria, viruses, parasites, or chemical substances.Annually, approximately 600 million people fall sick after eating contaminated food, and 420,000 die, resulting in the loss of 33 million healthy life years (DALYs) worldwide (Food Safety fact sheet, WHO.) Foodborne diseases are more prevalent in underdeveloped and developing countries.Foodborne illnesses are underestimated because the affected people usually do not report their problems to the authority due to process complexity.Only those who seek medical attention at clinics or hospitals are reported to the public health authorities (Odeyemi et al., 2019;WHO, 2015).Although there are insu cient investigations and studies on surveillance of foodborne illnesses in Bangladesh, it is reported that 30 million people are affected annually by foodborne illnesses caused by harmful microorganisms (Rahman et al., 2018).Like many other countries, the food consumption behavior of consumers has changed, particularly among young adults in Bangladesh.Several studies showed that Bangladeshi students prefer local snacks/street foods (singara, puri, fuchka etc.), fast foods, sugary and carbonated drinks, junk food, and fried food regularly during their stay in educational institutions (Chowdhury, 2014;Hasan et al., 2021).
Students usually buy these food items from the cafeteria, nearby restaurants, and street food vendors (Hasan et al., 2021).
Foodborne outbreaks occur associated with food prepared at and outside the home (Azanaw et al., 2021;Redmond et al., 2022).The lack of knowledge of food safety, poor personal hygiene, poor infrastructure, improper handling of food, unsafe water, poor conditions of producing and storing food, inadequate food safety laws, weak regulatory systems, and unsafe household preparation serve as the main factors to outbreaks of foodborne diseases in developing countries (Mshelia et al., 2022;Osaili et al., 2011;Sanlier & Konaklioglu, 2012;Sayuti et al., 2020).
The student groups are particularly prone to food hazards than other ages as they consume food with the risk of safety problems in and outside their homes (Aluh et al., 2021).Student life is the golden age of learning to develop their food safety knowledge, and skills, as well as to develop skills to understand contemporary food safety issues (Cheng et al., 2017).Educated consumers are what is needed in Bangladesh as they can function as food safety inspectors with a high level of knowledge in their own right.It is also seen that students either cooperate with their parents to prepare food or prepare food at home by themselves (Ovca et al., 2014).Hence, understanding the food safety knowledge, attitude, and practices of students is key to identifying ways to construct an appropriate educational intervention that would modify poor dietary patterns and increase the awareness of nutrition and food safety as well as minimize the risk of foodborne diseases.In addition, it is also helpful to spread knowledge of food safety, thereby in uencing a broader population (Jinfeng Sun et al., 2016).
There are many studies conducted in different countries, including Japan (Takeda et al., 2011), China (Luo et al., 2019b), Canada (Courtney et al., 2016), Lebanon (Hassan & Dimassi, 2014b), Malaysia (Mshelia et al., 2022), India (Rakshna et al., 2021), etc. that explored food safety knowledge, attitude, and practices of various student groups.However, there is no formal study to evaluate the knowledge, attitude, and preventive practices towards food safety among students in Bangladesh to the best of our knowledge.Therefore, this study aims to assess the level of knowledge, attitude, and practices among students of Bangladesh.The information gained from this study would be utilized for health promotion, adoption of legislation and appropriate tools to increase knowledge, changing wrong beliefs concerning food safety, and food habits, and changing people's practices that increase the risk of foodborne diseases in general.

Study Design
The study is based on a cross-sectional anonymous online survey conducted from 1st January to 15th February 2022 to evaluate the knowledge of, attitude towards, and practices of food safety of students in Bangladesh.Participants in this survey had to be at least 8th graders enrolled in Bangladeshi educational institutions.A link to an online survey (SurveyCTO) was shared on social media (FB, Messenger, WhatsApp, and Email).Authors' social media connection databases were used to share the survey link, and the recipients were also requested to share the link with their connections.After completing the survey, participants were also asked to share the survey link with their connections.The study questionnaire was prepared in English (see supportive information or https://osf.io/nvzrw/)and then translated into Bengali.Several experts and pilot surveys were used to validate the questionnaire.

Sample Size and Actual Response
From the literature search of the identical studies, we assume that 50% of the study population have proper knowledge, a positive attitude, and good practices towards food safety.Then, the required minimum sample size is 512 calculated using the formula SS=(Z2*P(1-P)/α2 )*def*NR where Z=1.96 at 95% con dence level, prevalence, p=0.5 of having proper knowledge, a positive attitude, and good practices, the margin of error (α = 0.03); design effect (def= 1.6) for sampling variation (Mahmud et al., 2021;Mohsin et al., 2022); a social media response rate of 70% from a previous study (Hossain et al., 2021) conducted in Bangladesh.

Ethical Considerations
The study was approved by the Ethical Review Committee, Faculty of Biological Science and Technology, Jashore University of Science and Technology, Jashore-7408, Bangladesh with Ref: ERC/FBST/JUST/2022-96.At the outset, a section described the study's aim, the questionnaire's concept, assurances regarding respondents' con dentiality, and the study's voluntary nature.Additionally, it was indicated that participants could skip any question if it appeared to be sensitive.The online survey began with the respondents' informed consent and eligibility veri cation.The surveys for the participants aged <18 years were conducted by or with the consent of their parents/adult guardians.

Statistical Analysis
The analysis involved three goals: (i) assessing respondents' knowledge regarding food safety and its determinants, (ii) exploring the students' practices towards food safety and its associated factors (ii) examining students' attitudes towards food safety and its in uential factors.Respondents were asked 16 food safety knowledge-related questions.The students who answered correctly more than seven (≥ 50%) questions were coded as "1" and labeled as having " adequate knowledge".Otherwise, participants' knowledge was coded as "0" and labeled as having " poor knowledge".Participants' attitude towards food safety was de ned as "favorable attitude" and coded as "1" if the respondents correctly answered ve or more questions out of the total nine and otherwise de ned as "unfavorable attitude" and coded as "0".Students were asked 12 food safety practices-related questions.If one correctly answered six or more questions the overall respondents' practices toward food safety were considered as "good practice", otherwise "bad practice" (Mahmud et al., 2021).
Participants' socio-demographic characteristics were examined by percentage/frequency analysis.The statistical signi cance of the association between socio-demographic factors and knowledge of the respondents and their practice and attitude toward food safety was tested using the Chi-square test.Potentially relevant covariates were identi ed using the Chi-square test at a 10% level of signi cance and were included in the univariate logistic regressions (Mahmud et al., 2022) We also estimated the adjusted odds ratios (AOR) in multivariate logistic regressions by adjusting all potential covariates identi ed from the Chi-square test.The correlation between the knowledge of the students and their practice and attitude towards food safety was inspected.The Statistical software STATA version 16.0 was used for performing all analyses.

Background Characteristics
The background characteristics of participants are presented in Table 1.A total of 777 students participated in the study.The majority of the respondents are male (63.96%) and aged between 18-25 years (60%) and Muslim (90.05%).Almost half of the respondents were at the undergraduate level (Honors/Degree/Equivalent) and 27.28% were at the graduate level (Master's or Ph.D.).Few respondents (23.68%) completed any food safety courses.Around 37% of the respondents studied Arts and Humanities and 26% studied Science During the study, less than half of the participants (45%) lived with their families.Most of the respondent's mothers and fathers had at least a primary level of education, only around 7% of the respondents had illiterate fathers and 8% had illiterate mothers.

Knowledge of food safety
Out of 16 food safety-related questions, only 46.54% of the respondents answered correctly at least 8 questions (Fig. 1).However, a large proportion (86.74%) of the respondents correctly knew that food decay is caused by microorganisms (Table 2).A lower portion of participants (6.96%) believed that pregnant women are less likely to get food poisoning while 64.22% of the respondents correctly knew that teenagers/ younger adults are less likely to get food poisoning.A person with Diarrhea should not be involved in food preparation for others was correctly answered by 47% of the respondents.A large proportion (73.87%) of the respondents believed that a balanced diet is the healthiest lifestyle whereas only 17% of the respondents thought that "control body weight moderately" is the healthiest lifestyle.The majority (80.82%) of the participants maintained that expired food should not be eaten.Around 72% of the respondents knew that knives should be washed with soap and water.Only 16.73% of the respondents knew that most disease-causing bacteria can grow within a temperature range between 5-60˚ C.About 40% of the participants knew that the recommended temperature for freezers is -18˚C or below and 4˚C for fridges was known by 56.73% of the respondents.Three to four days should leftovers be stored in the refrigerator was stated correctly by only 23% of the respondents.At most 32% of the participants knew that for any food to be safe to eat, it needs to be cooked until its internal temperature reaches 74˚C.
A respondent was considered to have adequate knowledge if he/she answered correctly more than seven out of 16 questions.Among a total of 777 respondents, 43.86% (218) males and 51.99% (145) females had adequate knowledge about food safety (Table 3).The ndings from logistic regression showed females had 1.37 times higher odds of having adequate knowledge of food safety than males.

Attitude towards food safety
More than half of the respondents were very concerned regarding the issue of food safety and thought the food safety situation is very poor in Bangladesh (Table 4).There were several causes for food safety problems stated by respondents.The majority of the respondents (68%) stated "food adulteration by food business operators in the hope of making more pro t", 67% expressed "lack of food safety knowledge", 58% expressed "lax enforcement of the law", 55% stated "consumer unawareness" and, 44% stated, "relevant departments are not clear about their responsibilities" and 46% stated, "lack of coordination among food regulatory agency" were the main causes of numerous food safety problems in Bangladesh.
Almost 70% of the respondents believe that improving the national awareness of food safety could ensure food safety whereas 76% think that strict enforcement of the law could improve food safety.A large proportion of the respondents, 63% and 47% also believed that supervision by public opinion and strengthening national legislation respectively could ensure food safety.In addition, more than 50% of the respondents were worried about the use of food additives, 47% were worried about pesticide residues, 43% were worried about the transfer of plasticizers in food containers and packaging materials, 38% were worried about heavy metals and microbe pollution, and only 27% worried about veterinary drug residue.
However, more than 94% of the respondents were willing to enrich their knowledge of food safety and willing to improve the food safety situation in their homes, educational institutions (canteen/halls), restaurants, and streets where they eat frequently.Moreover, more than 80% of respondents believed that the presence of pesticide residues on fruits/vegetables is alarming.An almost identical number of respondents were concerned about the current situation of food safety in educational institutions and thought that students can play a signi cant role in improving the food safety situation in Bangladesh.Overall, a very large portion (87%) of the respondents showed good/favorable attitudes toward food safety (Fig. 2).
The logistics regression showed that female students were more likely to have good food safety attitudes (UOR = 1.53, 95% CI:0.95, 2.45) (Table 5).Students with a higher level of education had a higher chance to show good attitudes regarding food safety in Bangladesh.Respondents who were at college (Grade

Practices toward food safety
Table 6 shows the frequency of practices toward food safety among participating students in Bangladesh.Almost 56% of the respondents never read the labels or expiry dates of packaged food before purchasing.However, 67% of the students never ate food that deteriorated and expired.Around 80% of the participants always bought food from small restaurants and street peddlers.An identical proportion of students decided to eat less of certain food because they were worried about its safety.
More than 55% of the participants shared that they never washed their hands before taking food, never stored food according to food labels, never consumed food kept at room temperature for long, and never stored raw chicken or meat separately from cooked food.Around 75% of the participants always washed dishes with detergent and water or in a dishwasher after preparing food and before new usage.
Overall 51.67% of the participating students showed good practices toward food safety (Fig. 3).Among the female students, 72% and among the male students, 40% showed good practices regarding food safety (Table 7).Findings from logistic regressions show that females were almost 4 times (AOR = 4.19, 95% CI: 2.97, 5.90) more likely to do good practices compared to their male counterparts (Table 7).In addition, respondents who had higher-level education were more likely to show good food safety practices.Students who were in undergraduate (Honors/Degree/Equivalent), and graduate (Master's/PhD) studies respectively were 3.37 times (95% CI: Figure 4 shows that students' attitudes and practices toward food safety improved with the increase in students' knowledge of food safety.In addition, the food safety practices also showed an upward trend among Bangladeshi students with increasing attitudes scores among them.The pairwise correlation test also reveals that the food safety knowledge was signi cantly associated with food safety attitudes (r = 0.27, p-value < 0.001) and food safety practices (r = 0.31, p-value < 0.001) and food safety attitudes were with food safety practices (r = 0.29, p-value < 0.001) among participating students in Bangladesh.

Discussion
Foodborne diseases are characterized as a burning public health issue in industrialized and middleincome nations (Sharif & Al-Malki, 2010).In most cases, foodborne diseases occur because of improper food preparation or mishandling at home, food service establishments, or street food vendors (Food Safety factsheet, WHO; Rane, 2011).In addition to eating food handled by parents, students also take food from the outside like food service outlets/canteens in educational institutions, restaurants, and street food vendors.The hygienic practices of food preparation are rarely maintained in these places, especially by small restaurants and street food vendors which has been a great public health concern for years (Amegah et al., 2020;Her et al., 2019;Wen-Hwa & Ko, 2011).The current study focused on evaluating the Bangladeshi student's basic food safety knowledge, attitudes, and practices when buying, preparing, and storing foods and on the role of a student as a food consumer which plays an important role in the reduction of foodborne illnesses.
In this cross-sectional study, the participants' responses (Fig. 1) revealed that a larger proportion of the students (53.46%) were poor in overall food safety knowledge.The inadequate level of food safety knowledge among students was also reported in previous similar kinds of studies (Ashkanani et , 2012).In this study, it was revealed that 47% of the respondent knew that a person with Diarrhea should not be involved in food preparation for others but it is reported in a study that only 9.4% of students of Lebanese university knew about this (Hassan & Dimassi, 2014b).It is reported that if food is left in the danger zone temperature (5-60˚ C), within 20 minutes, the bacteria multiply and double their number which increases the threat of foodborne diseases (FSIS, USDA).
However, only 16.73% of the respondents knew the food contamination danger zone (5-60˚ C) for food safety which was in line with the previous ndings (Hassan & Dimassi, 2014b).In addition, students also had low correct response percentages on "the recommended temperature for freezers is -18˚C or below", "three to four days should leftovers be stored in the refrigerator", "any food to be safe to eat, it needs to be cooked until its internal temperature reaches 74˚C".Such outcomes point out an increased risk of foodborne illnesses, as they reveal an extensive lack of knowledge about basic food safety.
This study found that females were more knowledgeable in terms of food safety knowledge than their male counterparts (Table 3).In addition, female students outperformed male students in terms of food safety attitudes and practices (  (Sun et al., 2015).This difference might be due to dissimilarity in their sociodemographic pro le, study period, study area, and study design.Though lack of su cient knowledge was revealed regarding food safety, the attitude of students towards food safety was demonstrated to be at a great level.This report was supported by the study conducted at Shahid Sadoughi University of Medical Sciences in Iran (Eslami et al., 2015).In our study, students were concerned about food safety issues.Among them, the respondents were most worried about the use of food additives (54%), pesticide residues (47%), transfer of plasticizers in food containers and packaging materials (43%), heavy metals, and microbe pollution (38%), and veterinary drug residue (27%).A study by Sun et al., 2015 found that students were most worried about the use of food additives (43.7), pesticide residues (9.5), and heavy metals and microbe pollution (46.8).More than 80% of respondents worried about the food safety of small restaurants and street food which was quite a similar nding toCheng et al., 2017 study.In this study, it was found that more than 94% of the student keen to enrich their knowledge of food safety and willing to improve the food safety situation of their educational institution canteen/hall, home, as well as restaurants/streets where they eat frequently.It was also revealed from this study that more than 80% of respondents think a student can play a signi cant role to improve the food safety situation in Bangladesh.These positive attitudes of students could be utilized with utmost care for the improvement of the food safety situation in Bangladesh as the students are going to be the leaders/head of their families.Before that students need to be equipped with proper food safety knowledge and food safety-related agencies should come forward in this regard.In logistic regression analysis, it was found gender, level of education, having food safety courses and mother's education were signi cantly correlated with students' attitudes towards food safety.Around 50% of the respondents had good practice toward food safety (Fig. 3).Concerning food safety practices, the majority of the students (65%) showed risky behavior by storing raw chicken or meat separately from cooked food.This risky behavior can lead to cross-contamination of microorganisms from raw food to cooked foods which may cause foodborne illnesses.The participants displayed a poor habit of checking labels or expiry dates of packaged foods before buying, storing foods according to food labels, and washing hands before eating food.Although there is a difference in the study setting, this nding is lower than other studies done in Bulgaria and China (Cheng et al., 2017;Stratev et al., 2017).However, the majority of the students displayed good habits of unwillingness to eat deteriorated and expired food, and not consuming food kept at room temperature for long.This nding is consistent with a study conducted in China (Luo et al., 2019b).Most of the surveyed students always wash dishes with detergent and water or in a dishwasher after preparing food and before new usage.This nding is similar to those reported by Stratev et al., 2017.A considerable number of students reported that they purchased food from small restaurants and street peddlers, though as many as 85.33% of the students showed anxiety about the safety of food prepared by them.It is observed from the data that many chose to omit their concerns and continued buying food from these places.According to Byrd-Bredbenner et al., 2008, when the stage of change (movement to higher stages) and self-e cacy increased, risky eating scores decreased.Food safety strategies and education ameliorating self-e cacy may be a key to helping students move to the next stage of action ( rm changes in food safety behavior are happening).
In logistic regression analyses, it was found that the food safety practices were in uenced by gender, education level, having a food safety course as well as mother's education level.This study, to the best of our knowledge, is the rst that explored the knowledge, attitudes, and practices toward food safety among the student population in Bangladesh.Also, our sample size is large enough for statistical tests to have signi cant power.However, this study has some limitations.First, surveys were conducted online and distributed through social media connections/databases.Therefore, those who didn't have access to the internet/social media, could not participate.Second, the proportion of younger student participants (< 18 years) was as low as 11%.The study ndings would be stronger if we could survey more young students (grades 8-12).

Conclusion
Understanding young children's food safety knowledge, attitudes, and practices is critical to identifying methods to improve training and reduce the risk of foodborne diseases.It is especially important for Bangladeshi students because almost half of the Bangladeshi students stay away from home while studying.However, food safety is understudied in Bangladesh despite being a signi cant public health concern.In this study, we found that poor levels of knowledge and bad practices toward food safety among Bangladeshi students were highly prevalent.Male students and students at younger ages were at higher risk of showing poor knowledge and bad practices toward food safety.However, a training/course on food safety signi cantly improved knowledge, attitudes, and practices among students.A chapter on food safety can be included in the textbooks for primary/elementary and high school level education.
Training on food safety at educational institutions is highly recommended for improving food safety knowledge and practices among students.

Declarations Figures
Distribution of knowledge of food safety among students in Bangladesh Distribution of attitudes regarding food safety and security among students of Bangladesh Correlation matrix among food safety knowledge, attitudes, and practices of students in Bangladesh These ndings are supported by studies conducted by Al-Shabib et al., 2017; Azanaw et al., 2021; Luo et al., 2019.

Table 3 :
Among those who completed a food safety course/training, 54.89% had adequate knowledge regarding food safety.Students who had food safety courses were 1.58 times likelier to have adequate knowledge compared to those who did not have any food safety courses.The education level of the participants' Association between knowledge of food safety and sociodemographic characteristics among students in Bangladesh (40)ers was signi cantly associated with having adequate knowledge of food safety.Participants whose mothers had a high school (Grade 6-10) degree, undergraduate (Honors/Degree/Equivalent), and graduate (Master's/PhD) degree were respectively 1.88, 2.50, 3.26 times more likely to have adequate knowledge compared to those whose mothers were illiterate.Which of the following statement is correct regarding the food expiration date?Expired food can be eaten as long as it appears good 8.37 (65)In the fridge (not freezer) of your house, where should the raw meat be stored?I don't know 5.15(40)When is the best time to purchase raw sh/meat, raw milk, and frozen food when shopping?

Table 5 :
Grade 6-10).Respondents who completed any food safety course were more likely (AOR = 2.94, 95% CI: 1.50, 5.76) to have good attitudes towards food safety.Similarly, Sons/daughters of highly educated mothers were more likely to have good attitudes regarding food safety in Bangladesh.Association between attitudes towards food safety and socio-demographic characteristics of [11][12], undergraduate (Honors/Degree/Equivalent), and graduate levels (Master's/PhD) respectively had 3.61 times (95% CI: 1.58, 8.26), 8.38 times (95% CI: 3.86, 18.15) and 8.23 times (95% CI: 3.54, 19.12) higher chance of having good attitudes towards food safety compared to the students who were at high school (

Table 7 :
Association between practices towards food safety and socio-demographic characteristics of

Table 5
&7).This may be because fLazou et al., 2012;Osaili et al., 2011)in food handling in the household as well as maintaining the kitchen hygiene and sanitation in Bangladesh.This nding conforms to the previous study, in which female students answered better than male students(Hassan & Dimassi, 2014b;Lazou et al., 2012;Osaili et al., 2011).Multivariate analysis showed that those who completed food safety courses were more knowledgeable than those who haven't completed them.These results suggest that food safety-related book chapters or topics can be incorporated into the curriculum to further improve the current food safety knowledge level among students by consultation with the appropriate authority.It was also found that mothers' education has a signi cant impact on the food safety knowledge of students.This can be since students are closer to their mothers than fathers acquired basic food safety knowledge from their mothers.
(Abolhassani et al., 2018)2)racteristic that may impact food safety practices, consequently reducing the incidence of foodborne illnesses (Abdullah Sani & Siow, 2014;Sanlier & Konaklioglu, 2012).In this study, from the overall attitude questions, 87% of the study participants had a positive attitude toward food safety.It was higher than ndings conducted in Ethiopia(Azanaw et al., 2021), Iran(Abolhassani et al., 2018), and China These ndings were not consistent with the report of Azanaw et al., 2021, but were consistent with the report ofEslami et al., 2015 and Abolhassani et al., 2018.