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Food safety knowledge, attitudes and practices among consumers in developing countries: An international survey
Accepted Manuscript Food safety knowledge, attitudes and practices among consumers in developing countries: An international survey
Olumide A. Odeyemi, Norrakiah Abdullah Sani, Obadina Adewale, Courage Kosi Setsoafia Saba, Florence A. Bamidele, Mahmoud Abughoush, Ali Asghar, Fabrice Fabien Dongho Dongmo, Darryl Macer, Ali Aberoumand PII: DOI: Reference:
S0963-9969(18)30816-0 doi:10.1016/j.foodres.2018.10.030 FRIN 8000
To appear in:
Food Research International
Received date: Revised date: Accepted date:
15 June 2018 5 October 2018 7 October 2018
Please cite this article as: Olumide A. Odeyemi, Norrakiah Abdullah Sani, Obadina Adewale, Courage Kosi Setsoafia Saba, Florence A. Bamidele, Mahmoud Abughoush, Ali Asghar, Fabrice Fabien Dongho Dongmo, Darryl Macer, Ali Aberoumand , Food safety knowledge, attitudes and practices among consumers in developing countries: An international survey. Frin (2018), doi:10.1016/j.foodres.2018.10.030
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ACCEPTED MANUSCRIPT Food safety knowledge, attitudes and practices among consumers in developing countries: An international survey
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Olumide A Odeyemi1, 2*, Norrakiah Abdullah Sani3, Obadina Adewale4, Courage Kosi Setsoafia Saba5, Florence A. Bamidele6, Mahmoud Abughoush7, Ali Asghar8, Fabrice Fabien Dongho Dongmo9, Darryl Macer10, Ali Aberoumand11
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Institute for Marine and Antarctic Studies, University of Tasmania, Launceston, Australia Food safety and quality Unit, Centre for Research, Training and Development, Higis International Foundation, Nigeria 3 School of Chemical Sciences and Food Technology, Faculty of Science and Technology, National University of Malaysia, 43600, Bangi, Selangor, Malaysia 4 Deparment of Food Science and Technology, Federal University of Agriculture, Abeokuta, Nigeria 5 Department of Biotechnology, Faculty of Agriculture, University for Development Studies, Ghana 6 Department of Biological sciences, School of Applied Science, Yaba College of Technology, Nigeria 7 Department of Clinical Nutrition and Dietetics, Allied and Health Science College, Jordan 8 National Institute of Food Science and Technology, University of Agriculture, Faisalabad, Pakistan 9 Laboratory of Biochemistry, University of Douala, Douala, Cameroon 10 American University of Sovereign Nations, Sacaton, AZ 85147, USA 11 Behbahan Khatam Alanbia University of Technology, Behbahan, Iran Corresponding author: [email protected]; [email protected] 2
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Abstract
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An international survey among consumers in developing countries from Asia and Africa on food safety knowledge, attitudes and practices (KAP) was carried out using structured questionnaires. Data were collected from 453 consumers comprising 265 from Africa and 188 from Asia. Significant difference (p < 0.05) on food safety knowledge attitude and practice between consumers from Africa and Asia was observed. In Africa, consumers in Cameroon had the least food safety knowledge (73.15 ± 16.43) compared to Ghana (78.19 ± 15.84) and Nigeria (88.16 ± 8.88). Similarly, consumers in Iran had the least food safety knowledge (73.33 ± 19.84) in Asia compared to Malaysia (88.36 ± 11.64) and Pakistan (89.42 ± 9.89). Among the respondents, 89% were aware of food poisoning while 304 (67.1%) consume food kept for long at room temperature. There was significant difference (p < 0.05) in food safety knowledge, attitudes and practices of consumers between Africa and Asia. Overall, respondents from Asia have better food safety knowledge than respondents from Africa. Similarly, attitudes and practise of food safety is better in Asia than Africa.
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Keywords: Microbial food safety, food borne infections, hygiene, consumers
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A 1.
Introduction
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ACCEPTED MANUSCRIPT Infections and diseases arising from contaminated food remain threats to global public health (Havelaar et al., 2015; Luo et al., 2019; Stratev et al., 2017). Food safety awareness remains a major problem among consumers both in developed and developing countries. However, developing countries are mostly affected by foodborne diseases due to poor living standards, poor personal hygiene and lack of access to adequate medical treatment (Odeyemi and Bamidele, 2016). In the food supply chain, consumers are the last contact to food, therefore, consumers knowledge and
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practice of food safety play significant roles in foodborne disease outbreaks (Jevšnik et al., 2008). More than 35% foodborne disease cases occur
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at home according to WHO (Langiano et al., 2012). Various studies on consumers’ food safety knowledge, attitude and practice have carried out
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in different parts of the world (Agüeria et al., 2018; Al-Shabib et al., 2016; Asiegbu et al., 2016; Farahat et al., 2015; Jevšnik et al., 2008; Luo et al., 2019; Moreb et al., 2017; Nevin, 2009; Parry-Hanson Kunadu et al., 2016; Stratev et al.; Subba Rao et al., 2007; Tomaszewska et al., 2018; Trafialek et al., 2018). Most foodborne disease outbreaks among consumers have been associated with food consumed at home although these
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have either been under-reported and or under-diagnosed (Keegan et al., 2009; Redmond and Griffith, 2003; Vrbova et al., 2012). Misinterpretation
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of foodborne disease symptoms constitute one of the reasons why consumers and food handlers at home do not seek medical treatment (Lim et al.,
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2016).
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Ansari-Lari et al. (2010), reported low level food hygiene level of knowledge among food handlers in Iran. Absence of food safety monitoring and surveillance are reported in Pakistan (Akhtar, 2015). Poor food hygiene contributes to more than 50% of food borne disease outbreaks in Malaysia
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(Saad et al., 2013). Osaili et al. (2013) reported low level of food safety knowledge among food handlers and consumers in Jordan. In Nigeria,
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lack of enforcement of regulations from the different regulatory bodies instituted by the federal government, public ignorance of food safety awareness (Omojokun, 2013), food fraud and lack of accurate and updated data on foodborne diseases. Ababio and Lovatt (2015) stated that government intervention is required to help prevent food borne disease outbreaks in Ghana. Poor knowledge of food safety, awareness and practices among consumers, lack of government regulations and food safety initiatives have been reported in Cameroon (Sneyd and Sneyd, 2014).
ACCEPTED MANUSCRIPT Tomaszewska et al. (2018) compared food poisoning and food hygiene practices among consumers between Thailand and Poland. Similarly, Trafialek et al. (2018) investigated food hygienic practices among street vendors in China, Thailand, Greece and Poland. There is lack of published information on comparative studies of food safety awareness between Asia and Africa despite shared similarities. For example, both have high numbers of developing countries and disease outbreaks in the world compared to other continents. Similarly, both have highly populated countries
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such as China and India in Asia and Nigeria in Africa. This study, therefore, aims to compare the food safety knowledge, attitudes and practices
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among consumers from developing countries using selected countries in Asia and Africa as case studies thereby serving as reference for future
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study.
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Materials and methods
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Study population
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This current study involved participants from Asia (Iran, Jordan, Malaysia and Pakistan) and Africa (Ghana, Cameroon and Nigeria). These
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countries were selected based on convenience of sampling by the authors. The survey targeted between 100 to 120 respondents (consumers) in each country.
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Questionnaire development for data collection
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To avoid duplication, the questionnaire used in this study was obtained with permission from (Stratev et al., 2017). The questionnaire was later
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developed as an online survey tool using a google document (Low et al., 2016). A link to the questionnaire was sent to participants who consented to the study. An online survey was used due to logistic reasons and it is a faster means of self-administered surveys compared to face to face interviews. The questionnaire was firstly validated among participants who were not included in the final study. Responses from validation test/pilot test was used to modify the questions and subsequent subdivided the questions into (1) Demographic section covered age, gender, marital status and nationality of respondents; (2) Food safety knowledge: this section comprised of 20 questions on knowledge of participants on food
ACCEPTED MANUSCRIPT safety; (3) Food safety attitudes: comprised of 20 questions to know the attitude of participants towards food safety and (4) Food safety practices also comprised of 20 questions. Four variant Likert scale responses (correct, wrong, do not know and I cannot remember) were available for questions on food safety knowledge and practices while questions on food safety attitude had three (never, sometimes and frequently). Responses received were immediately stored in a database prior to statistical analysis.
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Statistical analysis
Responses were thoroughly checked. Incomplete responses were not included for statistical analysis. Descriptive statistics and analysis of variance (ANOVA) at 95% confidence level was carried out using Social Package for Social Scientist (SPSS) version 22 (Stratev et al., 2017).
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Results and discussion
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Demographic characteristics of respondents
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Four hundred and fifty-three (453) consumers comprising 265 from Africa and 188 from Asia participated in this study. Cameroon and Ghana
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had the highest respondents while the least was from Jordan (Table 1). Results of this study showed that more than half of the respondents 298 (65.5%) were youths between the ages of 21 – 25 respectively. More than half (55%) of the respondents were female while 81% were single. 3.2
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Food safety knowledge, attitudes and practices
Food safety knowledge between consumers from Africa and Asia differs significantly (p < 0.05) in this current study. In Africa, consumers in
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Cameroon had the least food safety knowledge (73.15 ± 16.43) compared to Ghana (78.19 ± 15.84) and Nigeria (88.16 ± 8.88) (Table 2). Similarly, consumers in Iran had the least food safety knowledge (73.33 ± 19.84) in Asia. More than half (58%) of the respondents cover their mouth with hands when coughing or sneezing (Table 3). Few (23%) respondents frequently taste and dish out food with unprotected hands while 48% sometimes do. It was observed that 78% wash fruits or vegetables before eating. Among the respondents, 3.8% never read the label while 33% sometimes read food labels. 48% respondents read the conditions of use and storage of packaged food. Among the respondents, 47% defrost food
ACCEPTED MANUSCRIPT outside the refrigerator while 34% sometimes wear accessories. The result of this survey shows that 44% reported that they never used an apron when cooking, 40% sometimes while only 15% frequently use apron when cooking. Almost half (47%) of the respondents never store raw food separate from cooked food. 45% sometimes covered their cut with bandages and used gloves. Approximately, 27% of the respondents never keep food unrefrigerated for more than 2 hours. Majority of the respondents (97%) believed that food safety knowledge is important to them (Table 4).
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Knowledge and attitude towards food safety affected respondents’ practice of food safety procedures (Table 5). Female respondents had more
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significant knowledge of food safety than male respondents (Table 6). There was significant difference (p < 0.05) in food safety knowledge,
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attitudes and practices of consumers between Africa and Asia. In Africa, respondents from Cameroon had the least food safety knowledge (73.15 ± 16.43) compared to Ghana (78.19 ± 15.84) and Nigeria (88.16 ± 8.88). Respondents in Iran had the least food safety knowledge (73.33 ± 19.84) in Asia (Table 7 and Table 8).
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Recently, due to increasing outbreaks of foodborne diseases globally, there has been increase in the studies on food safety knowledge, attitude and
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practice among consumers and food handlers (Agüeria et al., 2018; Low et al., 2016; Luo et al., 2019; Moreb et al., 2017; Parry-Hanson Kunadu
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et al., 2016; Stratev et al., 2017; Tomaszewska et al., 2018; Trafialek et al., 2018). This current study presented information on intercontinental food safety knowledge, attitude and practices. Young adults (21-25) constitute most of the respondents in this study. This was similar to the results
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of Lazou et al. (2012), who surveyed a group with 92% of respondents aged between 20 – 25 years of age. Similar to this current study, Stratev et al. (2017) reported 82% of the university students surveyed on food safety were singles. Nevin (2009) reported insufficient food safety
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knowledge among young consumers compared to adults. Parry-Hanson Kunadu et al. (2016) reported 76% female respondents. Low et al. (2016) that reported influence of gender and level of education on food safety knowledge among consumers in Malaysia. However, in this current study,
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gender does not influence food safety knowledge.
Many consumers were not aware of the likelihood of the food getting spoiled if left at room temperature for long. This was similar to the results of (Nevin, 2009). Food handlers, and or vendors are to properly cook food before serving or selling to consumers. Similarly, majority of food consumers do not read labels on food containers. It is therefore important that producers ensure safety of their food products from production to
ACCEPTED MANUSCRIPT point of sale. Control of foodborne diseases states from food production and food producers play significant role in food supply chain. Good agricultural practices (GAP) should be encouraged among producers. Use of pesticides and herbicides should be discouraged has chemical residues in food could result into food poisoning. Food handlers or vendors contribute to food borne diseases. Methods of such as storage of raw and cooked food, storage of food at abused temperature and lack of proper personal hygiene could lead to foodborne disease outbreaks among consumers.
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Therefore, proper storage temperature, continuous food safety training and surveillance are recommended for food handlers or vendors.
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Regulatory organizations in developing countries should enforce food safety standard procedures when registering food producers. In addition, periodic survey of food processing premises is recommended to ensure proper compliance of food producers to food safety procedures. Governments of developing countries should embark on nationwide food safety education and aware programs. Regular training of food vendor
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and producers is recommended. Governments of developing countries should also embark on nationwide foodborne diseases research. It was
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observed that most food borne diseases in developing countries are underreported. The government should ensure each hospital has a record of
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food borne disease cases and be sent monthly to a central well monitored database so to know the number of disease occurrence monthly, prevailing environment or cities as none of the countries surveyed had any now. This will help the government to strategize ways of curbing food borne
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disease outbreaks.
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Conclusion
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Consumers from Asia have better food safety knowledge, attitude and practices than from Africa. Consumers are the end users of food products. It is therefore important that consumers are aware of food borne diseases that could arise from consuming contaminated food. Consumers should report every case of foodborne disease symptom to the nearest hospital for proper treatment and record. Continuous surveillance of occurrence of foodborne pathogens in food should be carried out, food safety education program for food handlers is also encouraged and a national database
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References
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Ababio, Patricia Foriwaa, Lovatt, Pauline, 2015. A review on food safety and food hygiene studies in Ghana. Food Control 47, 92-97. Agüeria, Daniela Alejandra, Terni, Claudia, Baldovino, Víctor Manuel, Civit, Diego, 2018. Food safety knowledge, practices and attitudes of fishery workers in Mar del Plata, Argentina. Food Control 91, 5-11. Akhtar, Saeed, 2015. Food Safety Challenges—A Pakistan's Perspective. Critical Reviews in Food Science & Nutrition 55, 219-226. Al-Shabib, Nasser Abdulatif, Mosilhey, Sameh Hassan, Husain, Fohad Mabood, 2016. Cross-sectional study on food safety knowledge, attitude and practices of male food handlers employed in restaurants of King Saud University, Saudi Arabia. Food Control 59, 212-217. Ansari-Lari, Maryam, Soodbakhsh, Sahar, Lakzadeh, Leila, 2010. Knowledge, attitudes and practices of workers on food hygienic practices in meat processing plants in Fars, Iran. Food Control 21, 260-263. Asiegbu, Chioma V., Lebelo, Sogolo L., Tabit, Frederick T., 2016. The food safety knowledge and microbial hazards awareness of consumers of ready-to-eat street-vended food. Food Control 60, 422-429. Farahat, Mohamed F., El-Shafie, Mona M., Waly, Mostafa I., 2015. Food safety knowledge and practices among Saudi women. Food Control 47, 427-435.
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ACCEPTED MANUSCRIPT Havelaar, Arie H., Kirk, Martyn D., Torgerson, Paul R., Gibb, Herman J., Hald, Tine, Lake, Robin J., Praet, Nicolas, Bellinger, David C., de Silva, Nilanthi R., Gargouri, Neyla, Speybroeck, Niko, Cawthorne, Amy, Mathers, Colin, Stein, Claudia, Angulo, Frederick J., Devleesschauwer, Brecht, on behalf of World Health Organization Foodborne Disease Burden Epidemiology Reference, Group, 2015. World Health Organization Global Estimates and Regional Comparisons of the Burden of Foodborne Disease in 2010. PLoS Med 12, e1001923. Jevšnik, M., Hlebec, V., Raspor, P., 2008. Consumers’ awareness of food safety from shopping to eating. Food Control 19, 737-745. Keegan, Victoria A., Majowicz, Shannon E., Pearl, David L., Marshall, Barbara J., Sittler, Nancy, Knowles, Lewinda, Wilson, Jeffery B., 2009. Epidemiology of enteric disease in C-EnterNet’s pilot site – Waterloo region, Ontario, 1990 to 2004. The Canadian Journal of Infectious Diseases & Medical Microbiology 20, 79-87. Langiano, E., Ferrara, M., Lanni, L., Viscardi, V., Abbatecola, A. M., De Vito, E., 2012. Food safety at home: knowledge and practices of consumers. Zeitschrift fur Gesundheitswissenschaften = Journal of public health 20, 47-57. Lazou, Thomai, Georgiadis, Marios, Pentieva, Kristina, McKevitt, Aideen, Iossifidou, Eleni, 2012. Food safety knowledge and food-handling practices of Greek university students: A questionnaire-based survey. Food Control 28, 400-411. Lim, Tee-Ping, Chye, Fook Yee, Sulaiman, Mohd Rosni, Suki, Norazah Mohd, Lee, Jau-Shya, 2016. A structural modeling on food safety knowledge, attitude, and behaviour among Bum Bum Island community of Semporna, Sabah. Food Control 60, 241-246. Low, Wah Yun, Jani, Rohana, Halim, Hishamuddin Abdul, Alias, Abd Aziz, Moy, Foong Ming, 2016. Determinants of food hygiene knowledge among youths: A cross-sectional online study. Food Control 59, 88-93. Luo, Xinmiao, Xu, Xianglong, Chen, Hua, Bai, Ruixue, Zhang, Yan, Hou, Xiaorong, Zhang, Fan, Zhang, Yong, Sharma, Manoj, Zeng, Huan, Zhao, Yong, 2019. Food safety related knowledge, attitudes, and practices (KAP) among the students from nursing, education and medical college in Chongqing, China. Food Control 95, 181-188. Moreb, Nora A., Priyadarshini, Anushree, Jaiswal, Amit K., 2017. Knowledge of food safety and food handling practices amongst food handlers in the Republic of Ireland. Food Control 80, 341-349. Nevin, Sanlier, 2009. The knowledge and practice of food safety by young and adult consumers. Food Control 20, 538-542. Odeyemi, Olumide A, Bamidele, Florence A, 2016. Harnessing the potentials of predictive microbiology in microbial food safety and quality research in Nigeria. Future Science OA. Omojokun, Jane, 2013. Regulation and enforcement of legislation on food safety in Nigeria. INTECH Open Access Publisher. Osaili, Tareq M., Abu Jamous, Dima O., Obeidat, Bayan A., Bawadi, Hiba A., Tayyem, Reema F., Subih, Hadil S., 2013. Food safety knowledge among food workers in restaurants in Jordan. Food Control 31, 145-150. Parry-Hanson Kunadu, Angela, Ofosu, Daniel Baah, Aboagye, Eurydice, Tano-Debrah, Kwaku, 2016. Food safety knowledge, attitudes and self-reported practices of food handlers in institutional foodservice in Accra, Ghana. Food Control 69, 324-330. Redmond, Elizabeth C., Griffith, Christopher J., 2003. Consumer Food Handling in the Home: A Review of Food Safety Studies. J. Food Prot. 66, 130-161. Saad, Mazni, See, Toh Poh, Adil, Mohamed Azam Mohamed, 2013. Hygiene Practices of Food Handlers at Malaysian Government Institutions Training Centers. Procedia - Social and Behavioral Sciences 85, 118-127. Sneyd, Adam, Sneyd, Lauren Q, 2014. Food Security and Emerging Powers in Cameroon. Policy report, 1-5.
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ACCEPTED MANUSCRIPT Stratev, Deyan, Odeyemi, Olumide A., Pavlov, Alexander, Kyuchukova, Ralica, Fatehi, Foad, Bamidele, Florence A., Food safety knowledge and hygiene practices among veterinary medicine students at Trakia University, Bulgaria. Journal of Infection and Public Health 10, 778-782. Stratev, Deyan, Odeyemi, Olumide A., Pavlov, Alexander, Kyuchukova, Ralica, Fatehi, Foad, Bamidele, Florence A., 2017. Food safety knowledge and hygiene practices among veterinary medicine students at Trakia University, Bulgaria. Journal of Infection and Public Health 10, 778-782. Subba Rao, G. M., Sudershan, R. V., Rao, P., Vishnu Vardhana Rao, M., Polasa, K., 2007. Food safety knowledge, attitudes and practices of mothers: findings from focus group studies in South India. Appetite 49, 441-449. Tomaszewska, Marzena, Trafialek, Joanna, Suebpongsang, Pornsiri, Kolanowski, Wojciech, 2018. Food hygiene knowledge and practice of consumers in Poland and in Thailand - A survey. Food Control 85, 76-84. Trafialek, Joanna, Drosinos, Eleftherios H., Laskowski, Waclaw, Jakubowska-Gawlik, Katarzyna, Tzamalis, Periklis, Leksawasdi, Noppol, Surawang, Suthat, Kolanowski, Wojciech, 2018. Street food vendors’ hygienic practices in some Asian and EU countries – A survey. Food Control 85, 212-222. Vrbova, L., Johnson, K., Whitfield, Y., Middleton, D., 2012. A descriptive study of reportable gastrointestinal illnesses in Ontario, Canada, from 2007 to 2009. BMC Public Health 12, 970.
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Highlight
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Food safety knowledge, attitudes and practices (KAP) among consumers in developing countries from Asia and Africa was investigated. There was significant difference (p < 0.05) on food safety knowledge attitude and practice between consumers from Africa and Asia. In Africa, consumers in Cameroon had the least food safety knowledge and Iran in Asia There is significant awareness of food safety knowledge among respondents, there is need for improvement on food safety practices and interventions on food safety and foodborne diseases in developing countries.
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Graphical abstract
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Food safety model describing relationship between food safety knowledge, attitude and practices among consumers (Lim et al. 2016).
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ACCEPTED MANUSCRIPT Table 1: Demographic characteristics of respondents ___________________________________________________________________________ Characteristics Number (%) ___________________________________________________________________________ Age (Years) 16-20 49 (10.8%) 21-25 298 (65.8%) 26-30 75 (16.6%) 31-36 27 (6.0%) 37-above 4 (0.9%) Gender Female 249 (55%) Male 203 (45%) Marital status Single 371 (81.9%) Engaged 35 (7.7%) Married 46 (10.2%) Divorced 1 (0.2%) Nationality Cameroon 100 (22.10%) Ghana 116 (25.60%) Nigeria 49 (10.80%) Iran 51 (11.30%) Jordan 33 (7.30%) Malaysia 61 (13.50%) Pakistan 43 (9.50%) __________________________________________________________________________
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ACCEPTED MANUSCRIPT Table 2: Food safety knowledge among respondents ____________________________________________________________________________________________________________________ __ Responses Questions ___________________________________________________ X1 X2 X3 X4 ____________________________________________________________________________________________________________________ _ 1 Are you aware of food poisoning? 403(89.0%) 33(7.3%) 3(0.7%) 14(3.1%) 2 Have you experienced food poisoning? 229(50.6%) 73(16.1%) 47(10.4%) 104(23.0%) 3 Are you aware of how to prevent food poisoning? 345(76.2%) 59(13.0%) 11(2.4%) 38(8.4%) 4 Does use of gloves reduces the risk of food contamination? 338(74.6%) 48(10.6%) 10(2.2%) 57(12.6%) 5 Does food poisoning have health and economic effects on the society? 399(88.1%) 34(7.5%) 2(0.4%) 18(4.0%) 6 Vulnerable* individuals are more at risk of food poisoning? 375(82.8%) 39(8.6%) 6(1.3%) 33(7.3%) 7 Does hand washing before cooking reduces the risk of food contamination? 413(91.1%) 22(4.9%) 3(0.7%) 15(3.3%) 8 Washing of hands after handling raw food prevent food-borne diseases? 347(76.6%) 54(11.9%) 8(1.8%) 44(9.7% 9 Can diarrhea can be transmitted through contaminated food? 402(88.7%) 34(7.5%) 2(0.4%) 15(3.3%) 10 Microorganisms can be found on skin, nose and mouth of healthy handlers? 343(75.7%) 74(16.3%) 11(2.4%) 25(5.5%) 11 Personal hygiene can prevent food contamination? 416(91.8%) 18(4.0%) 1(0.2%) 18(4.0%) 12 Contaminated water can be a vehicle for food borne disease transmission? 418(92.3%) 31(6.8%) 3(0.7%) 1(0.2%) 13 Storing raw and cooked food together can cause contamination of food? 330(72.8%) 91(20.1%) 6(1.3%) 26(5.7%) 14 Food handlers with diarrhea can pose risk of food contamination? 387(85.4%) 47(10.4%) 1(0.2%) 18(4.0%) 15 Leftover food smelling good is still safe to eat? 147(32.5%) 69(15.2%) 2(0.4%) 235(51.9%) 16 Dishing and serving food with unprotected hands can cross contaminate food? 377(83.2%) 40(8.8%) 9(2.0%) 27(6.0%) 17 Unkempt and dirty nails can easily spread bacteria? 425(93.8%) 17(3.8%) 2(0.4%) 9(2.0%) 18 Uncovered abrasion or cuts can cause cross contamination of food? 400(88.3%) 31(6.8%) 8(1.8%) 14(3.1%) 19 Food borne illness can be acquired from consumption of contaminated food? 400(88.3%) 39(8.6%) 7(1.5%) 7(1.5%) 20 Inadequate cooking of raw food** can cause outbreak of food borne illness 384(84.8%) 47(10.4%) 4(0.9%) 18(4.0%) ____________________________________________________________________________________________________________________ X1: Correct; X2: Wrong; X3: Do not know; X4: I cannot remember. *Children, pregnant women and older people, **meat, chicken and vegetable
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Table 3: Food safety attitude among respondents _________________________________________________________________________________________________________
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Responses _________________________________ Y1 Y2 Y3 _________________________________________________________________________________________________________ 21 Do you wash your hands before and after cooking? 280(61.8%) 26(5.7%) 147(32.5%) 22 Do you consume food kept at room temperature for long? 40(8.8%) 109(24.1%) 304(67.1%) 23 Do you use your hand to cover your mouth while coughing or sneezing? 262(57.8%) 29(6.4%) 162(35.8%) 24 Do you taste and dish out food with unprotected hands? 103(22.7%) 133(29.4%) 217(47.9%) 25 Do you wash fruits and vegetables before eating? 354(78.1%) 10(2.2%) 89(19.6%) 26 Do you read label on use by and expiry date of packaged food before purchasing? 287(63.4%) 17(3.8%) 149(32.9%) 27 Do you read conditions of use and storage of packaged food? 220(48.2%) 38(8.4%) 195(43.0%) 28 Do you wash eggs before cooking or frying them? 159(35.1%) 166(36.6%) 128(28.3%) 29 Do you wash and rinse* used for raw meat before using them for other food? 330(72.8%) 29(6.4%) 94(20.8%) 30 Do you defrost frozen food outside the refrigerator? 211(46.6%) 48(10.0%) 194(42.8%) 31 Do you wear accessories like rings, bracelets when cooking food? 29(6.4%) 268(59.2%) 156(34.4%) 32 Do you use apron when cooking? 68(15%) 200(44.2%) 185(40.0%) 33 Do you store raw chicken or meat separately from food? 238(52.5%) 83(18.3%) 132(29.1%) 34 Do you manually wash dishes with detergent and water after preparing food? 284(62.7%) 36(7.9%) 133(29.4%) 35 Do you wash your hands before handling raw food? 215(47.5%) 70(15.5%) 168(37.1%) 36 Do you wash dishes with detergent before preparing food? 336(74.2%) 21(4.6%) 96(21.2%) 37 Do you cover your cut with bandage and use gloves? 166(36.6%) 85(18.8%) 202(44.6%) 38 Do you keep food unrefrigerated for more than 2hours? 120(26.5%) 123(27.2%) 210(46.2%) 39 Do you protect raw food from insects and rodents? 419(92.5%) 27(6.0%) 7(1.5%) 40 Do you protect cooked food from insects and rodents? 349(77.0%) 78(17.2%) 26(5.7%)
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Questions _____________________________________________
Responses
Z1 Z2 Z3 Z4 ______________________________________________________________________________________________________________________________ _____ 41 Washing hands after going to toilet prevents cross contamination. 432(95.4%) 10(2.2%) 3(0.7%) 8(1.8%) 42 Knowledge about food safety is important to you. 437(96.5%) 12(2.6%) 2(0.4%) 2(0.4%) 43 Consumption of expired food can cause food borne illness. 408(90.1%) 31(6.8%) 3(0.7%) 11(2.4%) 44 Defrosted food should not be frozen again. 293(64.7%) 112(24.7%) 7(1.5%) 41(9.1%) 45 It is not safe to store raw and cooked food together. 349(77.0%) 78(17.2%) 1(0.2%) 25(5.5%) 46 Cooking cutleries should be properly sanitized to prevent cross contamination. 426(94.0%) 21(4.6%) 2(0.4%) 4(0.9%) 47 Food and personal hygiene training is important to you. 434(87%) 31(6.8%) 19(4.2%) 9(2.0%) 48 Clean hand towels should be used to wipe hands after washing. 396(87.4%) 34(7.5%) 3(0.7%) 20(4.4%) 49 Best places to store raw meat or chicken in the refrigerator is on the bottom shelf. 427(94.2%) 15(3.3%) 3(0.7%) 8(1.8%) 50 It is important to read food label before purchase. 363(80.1%) 62(13.7%) 9(2.0%) 19(4.2%)
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Reheating food could cause cross contamination. 420(92.7%) 11(2.4%) 2(0.4%) 20(4.4%) 52 Proper cooking of food could prevent contamination . 289(63.8%) 121(26.7%) 4(0.9%) 39(8.6%) 53 Eggs should be properly washed before cooking or frying. 364(80.4%) 71(15.7%) 5(1.1%) 13(2.9%) 54 Frequent hand washing help to prevent food borne diseases. 326(72.0%) 96(21.2%) 3(0.7%) 28(6.2%) 55 Chopping different meat on the same cutting board should be avoided 442(97.6%) 8(1.8%) 3(0.7%) 1(0.2%) 56 Bacteria multiply easily at room temperature 28(6.2%) 10(2.2%) 343(75.7%) 71(15.7%) 57 Food poisoning is more common in developing countries than developed countries. 38(8.4%) 14(3.1%) 1(0.2%) 400(88.3%) 58 Food preparation area must be cleaned before and after preparing food 1(0.2%) 96(21.2%) 102(22.5%) 254(56.1%) 59 Towel used in the toilet can be used in the kitchen 1(0.2%) 370(81.7%) 11(2.4%) 71(15.7%) 60 Towel used to clean food contact surfaces should be used to clean hands 309(68.2%) 4(0.9%) 44(9.7%) 96(21.2%) _____________________________________________________________________________________________________________________________ Z1: Correct; Z2: Wrong; Z3: Do not know; Z4: I cannot remember.
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Table 5: Correlation of food safety knowledge, attitudes and practices level among respondents (n=453). Level Food safety knowledge - food safety practices Food safety knowledge - food safety attitude Food safety practices - food safety attitude ** Correlation is significant at the 0.01 level (2-tailed).
Pearson Correlation 0.457** 0.625** 0.616**
p < 0.01 < 0.01 < 0.01
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Table 6: Effect of gender, age and marital status on food safety knowledge, attitude and practices
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Characteristics
Respondents (%)
Gender Female Male
249 (55.0%) 204 (45.0%)
83.35 ± 13.48 76.52 ± 18.82
Age 16–20 21–25 26–30 31–36 37- Above
49 (10.8%) 298 (65.8%) 75 (16.6%) 27 (6.0%) 4 (0.9%)
78.34 ± 12.97 78.44 ± 17.16 86.93 ± 14.16 84.07 ± 15.26 90.00 ± 13.54
Mean ± Standard Deviation Knowledge Attitude Practices
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66.27 ± 23.85 64.05 ± 26.34
75.86 ± 13.34 72.90 ± 15.19
65.30 ± 20.37 62.42 ± 25.74 73.33 ± 23.25 72.84 ± 24.52 75.00 ± 16.67
73.80 ± 12.32 72.86 ± 15.07 78.89 ± 12.12 79.83 ± 9.76 90.28 ± 6.99
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Marital status Single 371(81.9%) 80.15 ± 15.78 64.60 ± 24.97 74.06 ± 14.20 Engaged 35(7.7%) 80.71 ± 18.52 65.71 ± 26.18 75.56 ± 15.67 Married 46 (10.2%) 80.87 ± 20.23 69.57 ± 24.17 77.17 ± 13.87 Table 7: Effect of country on food safety knowledge, attitude and practices among respondents Divorced 1 (0.2%) 85.00 100.00 88.89
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Table 7: Summaries of knowledge, attitude and practices of food safety among the countries Characteristics
Respondents (%)
Mean ± Standard Deviation
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Knowledge
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Country Cameroon
100 (22.1%)
Ghana
116 (25.6%)
Nigeria
Attitude
Practices
73.15 ± 16.43
51.67 ± 30.84
69.72 ± 15.50
78.19 ± 15.84
63.79 ± 19.94
72.22 ± 12.22
49 (10.8%)
88.16 ± 8.88
74.83 ± 17.39
82.31 ± 7.49
Jordan
33 (7.3%)
81.36 ± 19.54
65.66 ± 21.22
70.20 ± 18.26
Iran
51(11.3%)
73.33 ± 19.84
64.05 ± 28.16
71.24 ± 18.91
Malaysia
61(13.5%)
88.36 ± 11.64
71.04 ± 18.73
78.96 ± 10.14
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43(9.5%)
89.42 ± 9.89
82.95 ± 18.36
83.98 ± 6.44
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Table 8: Analysis of variance (ANOVA) of food safety knowledge, attitude, practices and comparison of means between Africa (n = 265) and
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Asia (n = 188) Source
Type III Sum
df
of Squares
Mean
7873.866a
Intercept
14266.873
Africa/Asia
7873.866
Africa Asia
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1
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Square
Food safety knowledge Corrected Model
F
1 1
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*CoM
Sig.
7873.866
27.619
.000
14266.873
50.044
.000
7873.866
27.619
.000 1.46 ± 7.12 9.93 ± 24.82
Food safety attitude Corrected Model
6094.570b
1
6094.570
29.223
.000
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10237.145
1
10237.145
49.087
.000
Africa/Asia
6094.570
1
6094.570
29.223
.000
Africa
1.10 ± 4.53
Asia
8.55 ± 21.77
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Food practices Corrected Model
8559.464
Intercept Africa/Asia
c
1
11155.726
8559.46
8559.464
1
11155.726
8559.46
30.130
1
39.268
30.130
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.000
0.62 ± 6.76
Africa Asia
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9.45 ± 24.91
a. R Squared = .058 (Adjusted R Squared = .056); b. R Squared = .061 (Adjusted R Squared = .059); c. R Squared = .063 (Adjusted R Squared = .061); *Comparison of means (CoM) ± St. Deviation
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Olumide A. Odeyemi, Norrakiah Abdullah Sani, Obadina Adewale, Courage Kosi Setsoafia Saba, Florence A. Bamidele, Mahmoud Abughoush, Ali Asghar, Fabrice Fabien Dongho Dongmo, Darryl Macer, Ali Aberoumand PII: DOI: Reference:
S0963-9969(18)30816-0 doi:10.1016/j.foodres.2018.10.030 FRIN 8000
To appear in:
Food Research International
Received date: Revised date: Accepted date:
15 June 2018 5 October 2018 7 October 2018
Please cite this article as: Olumide A. Odeyemi, Norrakiah Abdullah Sani, Obadina Adewale, Courage Kosi Setsoafia Saba, Florence A. Bamidele, Mahmoud Abughoush, Ali Asghar, Fabrice Fabien Dongho Dongmo, Darryl Macer, Ali Aberoumand , Food safety knowledge, attitudes and practices among consumers in developing countries: An international survey. Frin (2018), doi:10.1016/j.foodres.2018.10.030
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ACCEPTED MANUSCRIPT Food safety knowledge, attitudes and practices among consumers in developing countries: An international survey
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Olumide A Odeyemi1, 2*, Norrakiah Abdullah Sani3, Obadina Adewale4, Courage Kosi Setsoafia Saba5, Florence A. Bamidele6, Mahmoud Abughoush7, Ali Asghar8, Fabrice Fabien Dongho Dongmo9, Darryl Macer10, Ali Aberoumand11
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Institute for Marine and Antarctic Studies, University of Tasmania, Launceston, Australia Food safety and quality Unit, Centre for Research, Training and Development, Higis International Foundation, Nigeria 3 School of Chemical Sciences and Food Technology, Faculty of Science and Technology, National University of Malaysia, 43600, Bangi, Selangor, Malaysia 4 Deparment of Food Science and Technology, Federal University of Agriculture, Abeokuta, Nigeria 5 Department of Biotechnology, Faculty of Agriculture, University for Development Studies, Ghana 6 Department of Biological sciences, School of Applied Science, Yaba College of Technology, Nigeria 7 Department of Clinical Nutrition and Dietetics, Allied and Health Science College, Jordan 8 National Institute of Food Science and Technology, University of Agriculture, Faisalabad, Pakistan 9 Laboratory of Biochemistry, University of Douala, Douala, Cameroon 10 American University of Sovereign Nations, Sacaton, AZ 85147, USA 11 Behbahan Khatam Alanbia University of Technology, Behbahan, Iran Corresponding author: [email protected]; [email protected] 2
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Abstract
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An international survey among consumers in developing countries from Asia and Africa on food safety knowledge, attitudes and practices (KAP) was carried out using structured questionnaires. Data were collected from 453 consumers comprising 265 from Africa and 188 from Asia. Significant difference (p < 0.05) on food safety knowledge attitude and practice between consumers from Africa and Asia was observed. In Africa, consumers in Cameroon had the least food safety knowledge (73.15 ± 16.43) compared to Ghana (78.19 ± 15.84) and Nigeria (88.16 ± 8.88). Similarly, consumers in Iran had the least food safety knowledge (73.33 ± 19.84) in Asia compared to Malaysia (88.36 ± 11.64) and Pakistan (89.42 ± 9.89). Among the respondents, 89% were aware of food poisoning while 304 (67.1%) consume food kept for long at room temperature. There was significant difference (p < 0.05) in food safety knowledge, attitudes and practices of consumers between Africa and Asia. Overall, respondents from Asia have better food safety knowledge than respondents from Africa. Similarly, attitudes and practise of food safety is better in Asia than Africa.
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Keywords: Microbial food safety, food borne infections, hygiene, consumers
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A 1.
Introduction
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ACCEPTED MANUSCRIPT Infections and diseases arising from contaminated food remain threats to global public health (Havelaar et al., 2015; Luo et al., 2019; Stratev et al., 2017). Food safety awareness remains a major problem among consumers both in developed and developing countries. However, developing countries are mostly affected by foodborne diseases due to poor living standards, poor personal hygiene and lack of access to adequate medical treatment (Odeyemi and Bamidele, 2016). In the food supply chain, consumers are the last contact to food, therefore, consumers knowledge and
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practice of food safety play significant roles in foodborne disease outbreaks (Jevšnik et al., 2008). More than 35% foodborne disease cases occur
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at home according to WHO (Langiano et al., 2012). Various studies on consumers’ food safety knowledge, attitude and practice have carried out
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in different parts of the world (Agüeria et al., 2018; Al-Shabib et al., 2016; Asiegbu et al., 2016; Farahat et al., 2015; Jevšnik et al., 2008; Luo et al., 2019; Moreb et al., 2017; Nevin, 2009; Parry-Hanson Kunadu et al., 2016; Stratev et al.; Subba Rao et al., 2007; Tomaszewska et al., 2018; Trafialek et al., 2018). Most foodborne disease outbreaks among consumers have been associated with food consumed at home although these
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have either been under-reported and or under-diagnosed (Keegan et al., 2009; Redmond and Griffith, 2003; Vrbova et al., 2012). Misinterpretation
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of foodborne disease symptoms constitute one of the reasons why consumers and food handlers at home do not seek medical treatment (Lim et al.,
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2016).
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Ansari-Lari et al. (2010), reported low level food hygiene level of knowledge among food handlers in Iran. Absence of food safety monitoring and surveillance are reported in Pakistan (Akhtar, 2015). Poor food hygiene contributes to more than 50% of food borne disease outbreaks in Malaysia
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(Saad et al., 2013). Osaili et al. (2013) reported low level of food safety knowledge among food handlers and consumers in Jordan. In Nigeria,
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lack of enforcement of regulations from the different regulatory bodies instituted by the federal government, public ignorance of food safety awareness (Omojokun, 2013), food fraud and lack of accurate and updated data on foodborne diseases. Ababio and Lovatt (2015) stated that government intervention is required to help prevent food borne disease outbreaks in Ghana. Poor knowledge of food safety, awareness and practices among consumers, lack of government regulations and food safety initiatives have been reported in Cameroon (Sneyd and Sneyd, 2014).
ACCEPTED MANUSCRIPT Tomaszewska et al. (2018) compared food poisoning and food hygiene practices among consumers between Thailand and Poland. Similarly, Trafialek et al. (2018) investigated food hygienic practices among street vendors in China, Thailand, Greece and Poland. There is lack of published information on comparative studies of food safety awareness between Asia and Africa despite shared similarities. For example, both have high numbers of developing countries and disease outbreaks in the world compared to other continents. Similarly, both have highly populated countries
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such as China and India in Asia and Nigeria in Africa. This study, therefore, aims to compare the food safety knowledge, attitudes and practices
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among consumers from developing countries using selected countries in Asia and Africa as case studies thereby serving as reference for future
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study.
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Materials and methods
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Study population
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This current study involved participants from Asia (Iran, Jordan, Malaysia and Pakistan) and Africa (Ghana, Cameroon and Nigeria). These
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countries were selected based on convenience of sampling by the authors. The survey targeted between 100 to 120 respondents (consumers) in each country.
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Questionnaire development for data collection
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To avoid duplication, the questionnaire used in this study was obtained with permission from (Stratev et al., 2017). The questionnaire was later
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developed as an online survey tool using a google document (Low et al., 2016). A link to the questionnaire was sent to participants who consented to the study. An online survey was used due to logistic reasons and it is a faster means of self-administered surveys compared to face to face interviews. The questionnaire was firstly validated among participants who were not included in the final study. Responses from validation test/pilot test was used to modify the questions and subsequent subdivided the questions into (1) Demographic section covered age, gender, marital status and nationality of respondents; (2) Food safety knowledge: this section comprised of 20 questions on knowledge of participants on food
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Statistical analysis
Responses were thoroughly checked. Incomplete responses were not included for statistical analysis. Descriptive statistics and analysis of variance (ANOVA) at 95% confidence level was carried out using Social Package for Social Scientist (SPSS) version 22 (Stratev et al., 2017).
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Results and discussion
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Demographic characteristics of respondents
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Four hundred and fifty-three (453) consumers comprising 265 from Africa and 188 from Asia participated in this study. Cameroon and Ghana
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had the highest respondents while the least was from Jordan (Table 1). Results of this study showed that more than half of the respondents 298 (65.5%) were youths between the ages of 21 – 25 respectively. More than half (55%) of the respondents were female while 81% were single. 3.2
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Food safety knowledge, attitudes and practices
Food safety knowledge between consumers from Africa and Asia differs significantly (p < 0.05) in this current study. In Africa, consumers in
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Cameroon had the least food safety knowledge (73.15 ± 16.43) compared to Ghana (78.19 ± 15.84) and Nigeria (88.16 ± 8.88) (Table 2). Similarly, consumers in Iran had the least food safety knowledge (73.33 ± 19.84) in Asia. More than half (58%) of the respondents cover their mouth with hands when coughing or sneezing (Table 3). Few (23%) respondents frequently taste and dish out food with unprotected hands while 48% sometimes do. It was observed that 78% wash fruits or vegetables before eating. Among the respondents, 3.8% never read the label while 33% sometimes read food labels. 48% respondents read the conditions of use and storage of packaged food. Among the respondents, 47% defrost food
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Knowledge and attitude towards food safety affected respondents’ practice of food safety procedures (Table 5). Female respondents had more
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significant knowledge of food safety than male respondents (Table 6). There was significant difference (p < 0.05) in food safety knowledge,
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attitudes and practices of consumers between Africa and Asia. In Africa, respondents from Cameroon had the least food safety knowledge (73.15 ± 16.43) compared to Ghana (78.19 ± 15.84) and Nigeria (88.16 ± 8.88). Respondents in Iran had the least food safety knowledge (73.33 ± 19.84) in Asia (Table 7 and Table 8).
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Recently, due to increasing outbreaks of foodborne diseases globally, there has been increase in the studies on food safety knowledge, attitude and
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practice among consumers and food handlers (Agüeria et al., 2018; Low et al., 2016; Luo et al., 2019; Moreb et al., 2017; Parry-Hanson Kunadu
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et al., 2016; Stratev et al., 2017; Tomaszewska et al., 2018; Trafialek et al., 2018). This current study presented information on intercontinental food safety knowledge, attitude and practices. Young adults (21-25) constitute most of the respondents in this study. This was similar to the results
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of Lazou et al. (2012), who surveyed a group with 92% of respondents aged between 20 – 25 years of age. Similar to this current study, Stratev et al. (2017) reported 82% of the university students surveyed on food safety were singles. Nevin (2009) reported insufficient food safety
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knowledge among young consumers compared to adults. Parry-Hanson Kunadu et al. (2016) reported 76% female respondents. Low et al. (2016) that reported influence of gender and level of education on food safety knowledge among consumers in Malaysia. However, in this current study,
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gender does not influence food safety knowledge.
Many consumers were not aware of the likelihood of the food getting spoiled if left at room temperature for long. This was similar to the results of (Nevin, 2009). Food handlers, and or vendors are to properly cook food before serving or selling to consumers. Similarly, majority of food consumers do not read labels on food containers. It is therefore important that producers ensure safety of their food products from production to
ACCEPTED MANUSCRIPT point of sale. Control of foodborne diseases states from food production and food producers play significant role in food supply chain. Good agricultural practices (GAP) should be encouraged among producers. Use of pesticides and herbicides should be discouraged has chemical residues in food could result into food poisoning. Food handlers or vendors contribute to food borne diseases. Methods of such as storage of raw and cooked food, storage of food at abused temperature and lack of proper personal hygiene could lead to foodborne disease outbreaks among consumers.
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Therefore, proper storage temperature, continuous food safety training and surveillance are recommended for food handlers or vendors.
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Regulatory organizations in developing countries should enforce food safety standard procedures when registering food producers. In addition, periodic survey of food processing premises is recommended to ensure proper compliance of food producers to food safety procedures. Governments of developing countries should embark on nationwide food safety education and aware programs. Regular training of food vendor
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and producers is recommended. Governments of developing countries should also embark on nationwide foodborne diseases research. It was
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observed that most food borne diseases in developing countries are underreported. The government should ensure each hospital has a record of
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food borne disease cases and be sent monthly to a central well monitored database so to know the number of disease occurrence monthly, prevailing environment or cities as none of the countries surveyed had any now. This will help the government to strategize ways of curbing food borne
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disease outbreaks.
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Conclusion
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Consumers from Asia have better food safety knowledge, attitude and practices than from Africa. Consumers are the end users of food products. It is therefore important that consumers are aware of food borne diseases that could arise from consuming contaminated food. Consumers should report every case of foodborne disease symptom to the nearest hospital for proper treatment and record. Continuous surveillance of occurrence of foodborne pathogens in food should be carried out, food safety education program for food handlers is also encouraged and a national database
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References
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Ababio, Patricia Foriwaa, Lovatt, Pauline, 2015. A review on food safety and food hygiene studies in Ghana. Food Control 47, 92-97. Agüeria, Daniela Alejandra, Terni, Claudia, Baldovino, Víctor Manuel, Civit, Diego, 2018. Food safety knowledge, practices and attitudes of fishery workers in Mar del Plata, Argentina. Food Control 91, 5-11. Akhtar, Saeed, 2015. Food Safety Challenges—A Pakistan's Perspective. Critical Reviews in Food Science & Nutrition 55, 219-226. Al-Shabib, Nasser Abdulatif, Mosilhey, Sameh Hassan, Husain, Fohad Mabood, 2016. Cross-sectional study on food safety knowledge, attitude and practices of male food handlers employed in restaurants of King Saud University, Saudi Arabia. Food Control 59, 212-217. Ansari-Lari, Maryam, Soodbakhsh, Sahar, Lakzadeh, Leila, 2010. Knowledge, attitudes and practices of workers on food hygienic practices in meat processing plants in Fars, Iran. Food Control 21, 260-263. Asiegbu, Chioma V., Lebelo, Sogolo L., Tabit, Frederick T., 2016. The food safety knowledge and microbial hazards awareness of consumers of ready-to-eat street-vended food. Food Control 60, 422-429. Farahat, Mohamed F., El-Shafie, Mona M., Waly, Mostafa I., 2015. Food safety knowledge and practices among Saudi women. Food Control 47, 427-435.
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ACCEPTED MANUSCRIPT Havelaar, Arie H., Kirk, Martyn D., Torgerson, Paul R., Gibb, Herman J., Hald, Tine, Lake, Robin J., Praet, Nicolas, Bellinger, David C., de Silva, Nilanthi R., Gargouri, Neyla, Speybroeck, Niko, Cawthorne, Amy, Mathers, Colin, Stein, Claudia, Angulo, Frederick J., Devleesschauwer, Brecht, on behalf of World Health Organization Foodborne Disease Burden Epidemiology Reference, Group, 2015. World Health Organization Global Estimates and Regional Comparisons of the Burden of Foodborne Disease in 2010. PLoS Med 12, e1001923. Jevšnik, M., Hlebec, V., Raspor, P., 2008. Consumers’ awareness of food safety from shopping to eating. Food Control 19, 737-745. Keegan, Victoria A., Majowicz, Shannon E., Pearl, David L., Marshall, Barbara J., Sittler, Nancy, Knowles, Lewinda, Wilson, Jeffery B., 2009. Epidemiology of enteric disease in C-EnterNet’s pilot site – Waterloo region, Ontario, 1990 to 2004. The Canadian Journal of Infectious Diseases & Medical Microbiology 20, 79-87. Langiano, E., Ferrara, M., Lanni, L., Viscardi, V., Abbatecola, A. M., De Vito, E., 2012. Food safety at home: knowledge and practices of consumers. Zeitschrift fur Gesundheitswissenschaften = Journal of public health 20, 47-57. Lazou, Thomai, Georgiadis, Marios, Pentieva, Kristina, McKevitt, Aideen, Iossifidou, Eleni, 2012. Food safety knowledge and food-handling practices of Greek university students: A questionnaire-based survey. Food Control 28, 400-411. Lim, Tee-Ping, Chye, Fook Yee, Sulaiman, Mohd Rosni, Suki, Norazah Mohd, Lee, Jau-Shya, 2016. A structural modeling on food safety knowledge, attitude, and behaviour among Bum Bum Island community of Semporna, Sabah. Food Control 60, 241-246. Low, Wah Yun, Jani, Rohana, Halim, Hishamuddin Abdul, Alias, Abd Aziz, Moy, Foong Ming, 2016. Determinants of food hygiene knowledge among youths: A cross-sectional online study. Food Control 59, 88-93. Luo, Xinmiao, Xu, Xianglong, Chen, Hua, Bai, Ruixue, Zhang, Yan, Hou, Xiaorong, Zhang, Fan, Zhang, Yong, Sharma, Manoj, Zeng, Huan, Zhao, Yong, 2019. Food safety related knowledge, attitudes, and practices (KAP) among the students from nursing, education and medical college in Chongqing, China. Food Control 95, 181-188. Moreb, Nora A., Priyadarshini, Anushree, Jaiswal, Amit K., 2017. Knowledge of food safety and food handling practices amongst food handlers in the Republic of Ireland. Food Control 80, 341-349. Nevin, Sanlier, 2009. The knowledge and practice of food safety by young and adult consumers. Food Control 20, 538-542. Odeyemi, Olumide A, Bamidele, Florence A, 2016. Harnessing the potentials of predictive microbiology in microbial food safety and quality research in Nigeria. Future Science OA. Omojokun, Jane, 2013. Regulation and enforcement of legislation on food safety in Nigeria. INTECH Open Access Publisher. Osaili, Tareq M., Abu Jamous, Dima O., Obeidat, Bayan A., Bawadi, Hiba A., Tayyem, Reema F., Subih, Hadil S., 2013. Food safety knowledge among food workers in restaurants in Jordan. Food Control 31, 145-150. Parry-Hanson Kunadu, Angela, Ofosu, Daniel Baah, Aboagye, Eurydice, Tano-Debrah, Kwaku, 2016. Food safety knowledge, attitudes and self-reported practices of food handlers in institutional foodservice in Accra, Ghana. Food Control 69, 324-330. Redmond, Elizabeth C., Griffith, Christopher J., 2003. Consumer Food Handling in the Home: A Review of Food Safety Studies. J. Food Prot. 66, 130-161. Saad, Mazni, See, Toh Poh, Adil, Mohamed Azam Mohamed, 2013. Hygiene Practices of Food Handlers at Malaysian Government Institutions Training Centers. Procedia - Social and Behavioral Sciences 85, 118-127. Sneyd, Adam, Sneyd, Lauren Q, 2014. Food Security and Emerging Powers in Cameroon. Policy report, 1-5.
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ACCEPTED MANUSCRIPT Stratev, Deyan, Odeyemi, Olumide A., Pavlov, Alexander, Kyuchukova, Ralica, Fatehi, Foad, Bamidele, Florence A., Food safety knowledge and hygiene practices among veterinary medicine students at Trakia University, Bulgaria. Journal of Infection and Public Health 10, 778-782. Stratev, Deyan, Odeyemi, Olumide A., Pavlov, Alexander, Kyuchukova, Ralica, Fatehi, Foad, Bamidele, Florence A., 2017. Food safety knowledge and hygiene practices among veterinary medicine students at Trakia University, Bulgaria. Journal of Infection and Public Health 10, 778-782. Subba Rao, G. M., Sudershan, R. V., Rao, P., Vishnu Vardhana Rao, M., Polasa, K., 2007. Food safety knowledge, attitudes and practices of mothers: findings from focus group studies in South India. Appetite 49, 441-449. Tomaszewska, Marzena, Trafialek, Joanna, Suebpongsang, Pornsiri, Kolanowski, Wojciech, 2018. Food hygiene knowledge and practice of consumers in Poland and in Thailand - A survey. Food Control 85, 76-84. Trafialek, Joanna, Drosinos, Eleftherios H., Laskowski, Waclaw, Jakubowska-Gawlik, Katarzyna, Tzamalis, Periklis, Leksawasdi, Noppol, Surawang, Suthat, Kolanowski, Wojciech, 2018. Street food vendors’ hygienic practices in some Asian and EU countries – A survey. Food Control 85, 212-222. Vrbova, L., Johnson, K., Whitfield, Y., Middleton, D., 2012. A descriptive study of reportable gastrointestinal illnesses in Ontario, Canada, from 2007 to 2009. BMC Public Health 12, 970.
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Food safety knowledge, attitudes and practices (KAP) among consumers in developing countries from Asia and Africa was investigated. There was significant difference (p < 0.05) on food safety knowledge attitude and practice between consumers from Africa and Asia. In Africa, consumers in Cameroon had the least food safety knowledge and Iran in Asia There is significant awareness of food safety knowledge among respondents, there is need for improvement on food safety practices and interventions on food safety and foodborne diseases in developing countries.
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Graphical abstract
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Food safety model describing relationship between food safety knowledge, attitude and practices among consumers (Lim et al. 2016).
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ACCEPTED MANUSCRIPT Table 1: Demographic characteristics of respondents ___________________________________________________________________________ Characteristics Number (%) ___________________________________________________________________________ Age (Years) 16-20 49 (10.8%) 21-25 298 (65.8%) 26-30 75 (16.6%) 31-36 27 (6.0%) 37-above 4 (0.9%) Gender Female 249 (55%) Male 203 (45%) Marital status Single 371 (81.9%) Engaged 35 (7.7%) Married 46 (10.2%) Divorced 1 (0.2%) Nationality Cameroon 100 (22.10%) Ghana 116 (25.60%) Nigeria 49 (10.80%) Iran 51 (11.30%) Jordan 33 (7.30%) Malaysia 61 (13.50%) Pakistan 43 (9.50%) __________________________________________________________________________
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ACCEPTED MANUSCRIPT Table 2: Food safety knowledge among respondents ____________________________________________________________________________________________________________________ __ Responses Questions ___________________________________________________ X1 X2 X3 X4 ____________________________________________________________________________________________________________________ _ 1 Are you aware of food poisoning? 403(89.0%) 33(7.3%) 3(0.7%) 14(3.1%) 2 Have you experienced food poisoning? 229(50.6%) 73(16.1%) 47(10.4%) 104(23.0%) 3 Are you aware of how to prevent food poisoning? 345(76.2%) 59(13.0%) 11(2.4%) 38(8.4%) 4 Does use of gloves reduces the risk of food contamination? 338(74.6%) 48(10.6%) 10(2.2%) 57(12.6%) 5 Does food poisoning have health and economic effects on the society? 399(88.1%) 34(7.5%) 2(0.4%) 18(4.0%) 6 Vulnerable* individuals are more at risk of food poisoning? 375(82.8%) 39(8.6%) 6(1.3%) 33(7.3%) 7 Does hand washing before cooking reduces the risk of food contamination? 413(91.1%) 22(4.9%) 3(0.7%) 15(3.3%) 8 Washing of hands after handling raw food prevent food-borne diseases? 347(76.6%) 54(11.9%) 8(1.8%) 44(9.7% 9 Can diarrhea can be transmitted through contaminated food? 402(88.7%) 34(7.5%) 2(0.4%) 15(3.3%) 10 Microorganisms can be found on skin, nose and mouth of healthy handlers? 343(75.7%) 74(16.3%) 11(2.4%) 25(5.5%) 11 Personal hygiene can prevent food contamination? 416(91.8%) 18(4.0%) 1(0.2%) 18(4.0%) 12 Contaminated water can be a vehicle for food borne disease transmission? 418(92.3%) 31(6.8%) 3(0.7%) 1(0.2%) 13 Storing raw and cooked food together can cause contamination of food? 330(72.8%) 91(20.1%) 6(1.3%) 26(5.7%) 14 Food handlers with diarrhea can pose risk of food contamination? 387(85.4%) 47(10.4%) 1(0.2%) 18(4.0%) 15 Leftover food smelling good is still safe to eat? 147(32.5%) 69(15.2%) 2(0.4%) 235(51.9%) 16 Dishing and serving food with unprotected hands can cross contaminate food? 377(83.2%) 40(8.8%) 9(2.0%) 27(6.0%) 17 Unkempt and dirty nails can easily spread bacteria? 425(93.8%) 17(3.8%) 2(0.4%) 9(2.0%) 18 Uncovered abrasion or cuts can cause cross contamination of food? 400(88.3%) 31(6.8%) 8(1.8%) 14(3.1%) 19 Food borne illness can be acquired from consumption of contaminated food? 400(88.3%) 39(8.6%) 7(1.5%) 7(1.5%) 20 Inadequate cooking of raw food** can cause outbreak of food borne illness 384(84.8%) 47(10.4%) 4(0.9%) 18(4.0%) ____________________________________________________________________________________________________________________ X1: Correct; X2: Wrong; X3: Do not know; X4: I cannot remember. *Children, pregnant women and older people, **meat, chicken and vegetable
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Table 3: Food safety attitude among respondents _________________________________________________________________________________________________________
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Responses _________________________________ Y1 Y2 Y3 _________________________________________________________________________________________________________ 21 Do you wash your hands before and after cooking? 280(61.8%) 26(5.7%) 147(32.5%) 22 Do you consume food kept at room temperature for long? 40(8.8%) 109(24.1%) 304(67.1%) 23 Do you use your hand to cover your mouth while coughing or sneezing? 262(57.8%) 29(6.4%) 162(35.8%) 24 Do you taste and dish out food with unprotected hands? 103(22.7%) 133(29.4%) 217(47.9%) 25 Do you wash fruits and vegetables before eating? 354(78.1%) 10(2.2%) 89(19.6%) 26 Do you read label on use by and expiry date of packaged food before purchasing? 287(63.4%) 17(3.8%) 149(32.9%) 27 Do you read conditions of use and storage of packaged food? 220(48.2%) 38(8.4%) 195(43.0%) 28 Do you wash eggs before cooking or frying them? 159(35.1%) 166(36.6%) 128(28.3%) 29 Do you wash and rinse* used for raw meat before using them for other food? 330(72.8%) 29(6.4%) 94(20.8%) 30 Do you defrost frozen food outside the refrigerator? 211(46.6%) 48(10.0%) 194(42.8%) 31 Do you wear accessories like rings, bracelets when cooking food? 29(6.4%) 268(59.2%) 156(34.4%) 32 Do you use apron when cooking? 68(15%) 200(44.2%) 185(40.0%) 33 Do you store raw chicken or meat separately from food? 238(52.5%) 83(18.3%) 132(29.1%) 34 Do you manually wash dishes with detergent and water after preparing food? 284(62.7%) 36(7.9%) 133(29.4%) 35 Do you wash your hands before handling raw food? 215(47.5%) 70(15.5%) 168(37.1%) 36 Do you wash dishes with detergent before preparing food? 336(74.2%) 21(4.6%) 96(21.2%) 37 Do you cover your cut with bandage and use gloves? 166(36.6%) 85(18.8%) 202(44.6%) 38 Do you keep food unrefrigerated for more than 2hours? 120(26.5%) 123(27.2%) 210(46.2%) 39 Do you protect raw food from insects and rodents? 419(92.5%) 27(6.0%) 7(1.5%) 40 Do you protect cooked food from insects and rodents? 349(77.0%) 78(17.2%) 26(5.7%)
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ACCEPTED MANUSCRIPT __________________________________________________________________________________________________________ Y1: Frequently; Y2: Never; Y3: Sometimes; *cutting board Table 4: Food safety practice among respondents
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Z1 Z2 Z3 Z4 ______________________________________________________________________________________________________________________________ _____ 41 Washing hands after going to toilet prevents cross contamination. 432(95.4%) 10(2.2%) 3(0.7%) 8(1.8%) 42 Knowledge about food safety is important to you. 437(96.5%) 12(2.6%) 2(0.4%) 2(0.4%) 43 Consumption of expired food can cause food borne illness. 408(90.1%) 31(6.8%) 3(0.7%) 11(2.4%) 44 Defrosted food should not be frozen again. 293(64.7%) 112(24.7%) 7(1.5%) 41(9.1%) 45 It is not safe to store raw and cooked food together. 349(77.0%) 78(17.2%) 1(0.2%) 25(5.5%) 46 Cooking cutleries should be properly sanitized to prevent cross contamination. 426(94.0%) 21(4.6%) 2(0.4%) 4(0.9%) 47 Food and personal hygiene training is important to you. 434(87%) 31(6.8%) 19(4.2%) 9(2.0%) 48 Clean hand towels should be used to wipe hands after washing. 396(87.4%) 34(7.5%) 3(0.7%) 20(4.4%) 49 Best places to store raw meat or chicken in the refrigerator is on the bottom shelf. 427(94.2%) 15(3.3%) 3(0.7%) 8(1.8%) 50 It is important to read food label before purchase. 363(80.1%) 62(13.7%) 9(2.0%) 19(4.2%)
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Reheating food could cause cross contamination. 420(92.7%) 11(2.4%) 2(0.4%) 20(4.4%) 52 Proper cooking of food could prevent contamination . 289(63.8%) 121(26.7%) 4(0.9%) 39(8.6%) 53 Eggs should be properly washed before cooking or frying. 364(80.4%) 71(15.7%) 5(1.1%) 13(2.9%) 54 Frequent hand washing help to prevent food borne diseases. 326(72.0%) 96(21.2%) 3(0.7%) 28(6.2%) 55 Chopping different meat on the same cutting board should be avoided 442(97.6%) 8(1.8%) 3(0.7%) 1(0.2%) 56 Bacteria multiply easily at room temperature 28(6.2%) 10(2.2%) 343(75.7%) 71(15.7%) 57 Food poisoning is more common in developing countries than developed countries. 38(8.4%) 14(3.1%) 1(0.2%) 400(88.3%) 58 Food preparation area must be cleaned before and after preparing food 1(0.2%) 96(21.2%) 102(22.5%) 254(56.1%) 59 Towel used in the toilet can be used in the kitchen 1(0.2%) 370(81.7%) 11(2.4%) 71(15.7%) 60 Towel used to clean food contact surfaces should be used to clean hands 309(68.2%) 4(0.9%) 44(9.7%) 96(21.2%) _____________________________________________________________________________________________________________________________ Z1: Correct; Z2: Wrong; Z3: Do not know; Z4: I cannot remember.
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Table 5: Correlation of food safety knowledge, attitudes and practices level among respondents (n=453). Level Food safety knowledge - food safety practices Food safety knowledge - food safety attitude Food safety practices - food safety attitude ** Correlation is significant at the 0.01 level (2-tailed).
Pearson Correlation 0.457** 0.625** 0.616**
p < 0.01 < 0.01 < 0.01
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Table 6: Effect of gender, age and marital status on food safety knowledge, attitude and practices
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Characteristics
Respondents (%)
Gender Female Male
249 (55.0%) 204 (45.0%)
83.35 ± 13.48 76.52 ± 18.82
Age 16–20 21–25 26–30 31–36 37- Above
49 (10.8%) 298 (65.8%) 75 (16.6%) 27 (6.0%) 4 (0.9%)
78.34 ± 12.97 78.44 ± 17.16 86.93 ± 14.16 84.07 ± 15.26 90.00 ± 13.54
Mean ± Standard Deviation Knowledge Attitude Practices
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66.27 ± 23.85 64.05 ± 26.34
75.86 ± 13.34 72.90 ± 15.19
65.30 ± 20.37 62.42 ± 25.74 73.33 ± 23.25 72.84 ± 24.52 75.00 ± 16.67
73.80 ± 12.32 72.86 ± 15.07 78.89 ± 12.12 79.83 ± 9.76 90.28 ± 6.99
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Marital status Single 371(81.9%) 80.15 ± 15.78 64.60 ± 24.97 74.06 ± 14.20 Engaged 35(7.7%) 80.71 ± 18.52 65.71 ± 26.18 75.56 ± 15.67 Married 46 (10.2%) 80.87 ± 20.23 69.57 ± 24.17 77.17 ± 13.87 Table 7: Effect of country on food safety knowledge, attitude and practices among respondents Divorced 1 (0.2%) 85.00 100.00 88.89
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Table 7: Summaries of knowledge, attitude and practices of food safety among the countries Characteristics
Respondents (%)
Mean ± Standard Deviation
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Knowledge
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Country Cameroon
100 (22.1%)
Ghana
116 (25.6%)
Nigeria
Attitude
Practices
73.15 ± 16.43
51.67 ± 30.84
69.72 ± 15.50
78.19 ± 15.84
63.79 ± 19.94
72.22 ± 12.22
49 (10.8%)
88.16 ± 8.88
74.83 ± 17.39
82.31 ± 7.49
Jordan
33 (7.3%)
81.36 ± 19.54
65.66 ± 21.22
70.20 ± 18.26
Iran
51(11.3%)
73.33 ± 19.84
64.05 ± 28.16
71.24 ± 18.91
Malaysia
61(13.5%)
88.36 ± 11.64
71.04 ± 18.73
78.96 ± 10.14
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43(9.5%)
89.42 ± 9.89
82.95 ± 18.36
83.98 ± 6.44
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Table 8: Analysis of variance (ANOVA) of food safety knowledge, attitude, practices and comparison of means between Africa (n = 265) and
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Asia (n = 188) Source
Type III Sum
df
of Squares
Mean
7873.866a
Intercept
14266.873
Africa/Asia
7873.866
Africa Asia
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1
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Food safety knowledge Corrected Model
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1 1
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*CoM
Sig.
7873.866
27.619
.000
14266.873
50.044
.000
7873.866
27.619
.000 1.46 ± 7.12 9.93 ± 24.82
Food safety attitude Corrected Model
6094.570b
1
6094.570
29.223
.000
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10237.145
1
10237.145
49.087
.000
Africa/Asia
6094.570
1
6094.570
29.223
.000
Africa
1.10 ± 4.53
Asia
8.55 ± 21.77
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8559.464
Intercept Africa/Asia
c
1
11155.726
8559.46
8559.464
1
11155.726
8559.46
30.130
1
39.268
30.130
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0.62 ± 6.76
Africa Asia
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9.45 ± 24.91
a. R Squared = .058 (Adjusted R Squared = .056); b. R Squared = .061 (Adjusted R Squared = .059); c. R Squared = .063 (Adjusted R Squared = .061); *Comparison of means (CoM) ± St. Deviation
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