Degree project, 30 credits

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Food hygiene knowledge, attitudes and practices of

food handlers in Bangladeshi homes

Degree project, 30 credits

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Abstract

Background

Food handlers knowledge and related attitude and practices towards food hygiene plays a significant role in reducing food-borne disease, which represents a growing concern for public health interest.

Aim

To explore the knowledge, attitudes and practices of food hygiene among food handlers in Bangladeshi homes located in urban areas exposed to climate change.

Methodology

A descriptive cross sectional study was conducted to perform this study. An online questionnaire survey was used as a tool for data collection. Food handlers were selected through convenience sampling method. Data were statistically analyzed using SPSS software version 27.

Results

In case of food hygiene knowledge, attitudes and practices, study participants had good knowledge (78.77%), moderate attitude (57.4%) and good practice level (88.82%) in food hygiene at home. There is no significant difference between men and women in their knowledge level but had significant difference in their attitude and practice level. Besides, there is no significant difference in food hygiene knowledge of food handlers based on their educational level but results showed significant difference in their attitude and practices of food hygiene.

Conclusion

Food handlers in Bangladeshi homes were knowledgeable with moderate attitude and good practice level. Continuous food safety education, health education and media campaigns will help them to reduce the risk of diarrhea and food-borne illness.

Key words

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Acknowledgments

My independent study would not be possible without the help and support of many people. First of all, I would like to thank and express my gratitude to Almighty Allah for blessing me to come to the end of this program. I am very much grateful to Linnaeus University for giving me the opportunity to study here and their continuous support to develop my academic skill. I am so much thankful to my thesis supervisor Dr. Kristina Tryselius for her valuable guidance and continuous support to complete my thesis successfully. I would like to praise my thesis supervisor for her patience who read and gave necessary comments while the thesis was taking its shape. Specially thanks to all study participants who gave their valuable time to participate in this study.

I would like to thank all the teachers, lecturers and staff of Linnaeus University for their helpful advice. Also, thank you my classmates for their kindness and support throughout the program.

Finally, I would like to thank my parents and my beloved husband for their support, love and encouragement during this program.

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4 Problem of statement ... 18 5 Aim ... 19 6 Research questions ... 19 7 Methodology ... 20 7.1 Study location ... 20 7.2 Population ... 20 7.3 Study design ... 21 7.4 Questionnaire design ... 21 7.4.1 Socio-demographic section ... 21 7.4.2 Knowledge section ... 22 7.4.3 Attitude section ... 22 7.4.4 Practice section ... 22 7.5 Sampling technique ... 22

7.6 Method for data collection ... 23

7.7 Method for data analysis ... 23

7.7.1 Descriptive analysis ... 23

8 Ethical consideration ... 24

9 Results ... 25

9.1 Descriptive analysis ... 25

9.2 Demographic data ... 26

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9.4 Food hygiene attitude level of participants ... 31

9.5 Food hygiene practice level of participants ... 32

9.6 Difference between men and women food hygiene knowledge, attitude and practice level ... 34

9.7 Educational difference between food handlers food hygiene knowledge, attitude and practice level ... 40

10 Discussion ... 44

10.1 General information of study subjects ... 45

10.2 Socio-demographic characteristics ... 45

10.3 Food handler’s knowledge of food hygiene ... 49

10.4 Food handlers’ attitude of food hygiene ... 51

10.5 Food handler’s practices of food hygiene ... 53

10.6 Food hygiene knowledge-attitude-practices and climate change ... 55

10.7 Food hygiene knowledge, attitudes and practices relevance for human and non human health in times of climate change ... 57

10.8 Transdisciplinary perspectives of food hygiene knowledge, attitudes and practices ... 59

10.9 Validity and Reliability of the study ... 61

10.10 Strengths and limitations of the study ... 61

11 Conclusion ... 63

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Appendices

Appendix 1- Information letter

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1 Introduction

Around the world, food-borne diseases remain one of the most important public health problems which cause significant amounts of morbidities and mortalities (Fariba et al., 2018; Mutalib et al., 2012). Every year 76 million food-borne illnesses occur with 5200 of mortality rates and 325000 of morbidity rates (Mutalib et al., 2012). In addition, more than one third of the world’s population suffers from food-borne related diseases (Hasanuzzaman et al, 2020). The most common food-borne disease, diarrhea affect annually around 550 million people worldwide (Tomaszewska et al., 2018). Thus, diarrheal diseases are prevalent in both developed and developing countries which have negative effect on human health and wellbeing (Akabanda et al., 2017; Ganta & kadeangadi, 2019).

1.1 Prevalence of diarrhea and others food-borne diseases in the world

According to the epidemiological studies, approximately 3.4 million diarrheal deaths occur each year globally, where 21 % are deaths of children under the age of five years (Ikeda et al., 2019). World Health Organization (WHO) stated that, diarrhea is the second leading cause of mortality among children under the age of five years in low and middle income countries (Aik et al., 2020; Bhandari et al., 2020). Children at this age group are the most vulnerable to diarrheal disease due to their undeveloped immune system (Thiam et al., 2017). Food-borne disease hits up to 30% of the population every year in developed countries while 2 million deaths occur per year in developing countries (Ezenowko et al., 2017). That’s why food safety is a growing concern for public health interest in order to reduce the burden of diarrhea and others food-borne diseases (Ezenwoko et al., 2017).

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pregnant women and individuals with chronic disease (Ezenowko et al., 2017; Eze & Anyeagbunam,2014). According to the WHO, 1.8 million people including women and children die every year from diarrhea due to consumption of contaminated food and water (WHO, 2015; Eze & Anyaegbunam, 2014; Akabanda et al., 2017). The WHO also highlights that almost one in ten people, from a global estimation of 600 million people fall sick due to the consumption of contaminated food (WHO, 2015; Ganta & Kadeangadi, 2019). Contamination of food not only means the presence of chemicals, toxins and physical contaminates but also the presence of microbial pathogens such as bacteria and viruses which are not safe for the human health (Eze & Anyaegbunam, 2014). Food contamination or food poisoning caused by microbial pathogens such as, Escherichia coli, Salmonella and Campylobacter is responsible for diarrhea and other food-borne diseases (Eze & Anyaegbunam, 2014). Evidence suggests that the transmission of these pathogens cause diarrheal disease which can be influenced by various climatic factors (Aik et al., 2020). Thus climate change is predicted as an important factor which impact food safety through microbial contamination on food.

1.2 Food contamination and climate change

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contaminated water. Therefore, increase in extreme weather events can increase the incidence of diarrhea which is one of the most common foodborne illness (Aik et al., 2020).

Over the past century , significant gain in public health and infectious disease control have led to reduction in deaths related to diarrhea each year, but still diarrheal diseases remain the most common cause of morbidity and mortality, especially in low and middle income countries (Lal et al., 2019). This is because different types of bacterial, viral and parasitic pathogen causes diarrheal disease which can be transmitted due to contamination of water and food (Aik et al., 2020). Extreme rainfall due to climate change can lead to most of the common natural disaster; flooding which affect human life through the outbreak of diarrheal disease (Nguyen et al., 2019). Flooding damage the sewage system and contaminate water sources which increase the chance of pathogen survival in the domestic wastewater. Thus, flooding occurs in an urban area combined with sewage system may pose a serious risk of diarrheal infection for people who are exposed to this water (Nguyen et al., 2019).

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for microbial contamination on fresh produce food. Also, it is found that, some pathogens can survive several days on fresh produced vegetables after the flooding outbreak occur (Nguyen et al., 2019). In addition, temperature and relative humidity have notifiable effect on the survivalibility and multiplication of microbial pathogens on food. Higher temperature increases the survivability and transmission of bacterial pathogen on food and drinking water where high relative humidity helps in replicate bacterial pathogen on fresh produced fruits and vegetables and ultimately impact food safety (Wangdi & Clements, 2017; Aik et al., 2020; Thiam et al., 2017; Nguyen et al., 2019). Therefore, climate change identified as a factor of food contamination during food preparation, handling and storage. But food contamination can prevent by understanding and following food safety guidelines from production to consumer level (Ezenowko et al., 2017). That highlights the importance of food hygiene by which food can keep safe from possible contamination and will reduce the risk of diarrhea.

1.3 Strategies of food hygiene

The term food hygiene is used to describe a process where safety practices such as food handling, preparation and storage is done in a way so that it can prevent microbial contamination at all stages of food chain to reduce food-borne illness (Oho & Onoh, 2018). To strengthen food hygiene principles, the WHO recommend Five keys to safer food for maintain food safety all over the world (Ganta & Kadeangadi, 2019; WHO, 2015). The message of the five keys to safer food are:

a) Keep clean

• Hands should be washed before handling food and often during food preparations

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• All surfaces and equipment used for food preparations should be washed and sanitized

•_{Kitchen areas and food should be protected from insects, pests and} other animals (WHO, 2015).

b) Separate raw and cooked food

• Raw meat, poultry and seafood should be separated from others food •_{Separate equipment and utensils such as knives and cutting board}

should be used for handling raw food and cooked food

• Food should be stored in separate containers to avoid contact between raw and cooked food (WHO, 2015).

c) Cook thoroughly

• Food should be cooked thoroughly

•_{Cooked food should be reheated thoroughly}

• Meat, poultry should be well cooked until the juices are clear (WHO, 2015).

d) Keep food at safe temperatures

•_{Cooked food should not leave at room temperatures more than two} hours

• Frozen food should not be thawed at room temperature

• All cooked and perishable food should be refrigerate promptly

•_{Food should not be stored too long even in the refrigerator (WHO,} 2015).

e) Use safe water and raw materials

• Safe water or treated water should be used

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• Fresh and wholesome food should be selected

•_{Processed food should be chosen for safety (WHO, 2015).}

Therefore, to reduce diarrheal disease burden these safety guidelines should be followed during food handling , storage and preparations across the globe.

1.4 Food handlers active role in food hygiene

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2 Review of literature in the field

Previous studies found some association between food hygiene knowledge and practices with diarrhea or food-borne diseases and also climatic parameters (temperature, rainfall, relative humidity and flooding) and the occurrence of diarrheal disease which is described in below.

2.1 Food hygiene and diarrheal or other food-borne diseases

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In addition, water is an essential element for hygienic food preparations and proper food handling, so the quality of water should be good enough to reduce the risk of diarrhea and other food-borne diseases. In most of the developing countries, the demand of safe drinking water is increased due to increasing population. To meet the demand of safe drinking water, Water Supply and Sewerage Authority (WASA) take initiatives to provide better water and sanitation facilities which main works to administering water supply, drainage and sanitation system in developing countries. A study carried out in the capital city of Bangladesh, Dhaka reported that the microbiological quality of the Water Supply and Sewerage Authority (WASA) drinking water should be free from bacterial load to reduce the risk of fecal contamination and outbreak of diarrheal disease (Mahmud et al., 2011).

2.2 Temperature and diarrhea

Several studies have found a strong association between temperature and diarrheal diseases in different countries (Aik et al., 2020; Azage et al., 2017; Bhandari et al., 2020; Das et al., 2017; Mertens et al., 2019; Musengimana et al., 2016; Thiam et al., 2017; Wangdi & Clements, 2017).

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According to Thiam et al. (2017) an increase in temperature has also been identified to increase the incidence of diarrhea in rural areas than urban areas. But increase in one degree Celsius in ambient temperature can increase 5-13 % of diarrhea cases in Kathmandu city areas (Bhandari et al., 2020). Studies made in Peru, Fiji and Dhaka city also reported that increase in temperature by one degree Celsius can increase diarrhea cases by 8%, 3% and 6% respectively (Musengimana et al., 2016). Also, one study in Singapore found positive association between ambient temperature and all causes of diarrhea (Aik et al., 2020).

In addition, a study made in Bhutan also found a positive association between higher temperature and diarrhea because higher temperature can cause food poisoning and influence human dietary and hygiene behavior due to shortage of water which leads to transmission of pathogens (Wangdi & Clements, 2017). Therefore, a rise in temperature have a significant effect on microbial pathogens which can cause food poisoning and leads to the outbreak of diarrheal disease.

2.2.1 Temperature and bacterial and viral pathogen

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2.3 Rainfall and flooding

According to Mertens et al. (2019) rainfall has positively associated with all causes of diarrhea. A study in Nepal found that 10 mm increase in monthly rainfall can increase diarrhea cases 0.9% (Bhandari et al., 2020). But a study in Rwanda found that low rainfall has also a strong association with diarrhea and can increase 2-8% of diarrheal incidence (Mukabutera et al., 2016). Though there is strong association between rainfall and diarrhea, this association is depended on the region or location because of the different pattern of transmission of predominant pathogens (Mertens et al., 2019). However, flooding has been identified as the most widespread hydro meteorological hazard under climate change and strongly linked with the outbreak of diarrhea in most vulnerable population (Alexander et al., 2018; Zhang et al., 2019). A study in India found that, diarrhea is highly associated with rainfall which increases the risk of diarrheal disease in rural population (Mertens et al., 2019). According to Alexander et al. (2018) a significant association was observed between floodplain system and diarrheal disease outbreak in the children under the age of five years. In addition, flooding due to heavy rainfall prevent the normal functioning of sewerage system and increase the transmission of microbial pathogens (Wangdi & Clements, 2017).

2.3.1 Seasonality and diarrheal disease

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diarrhea in India. Because human feces may be accumulated during dry periods which washed away after heavy rains and contact into children through hand to mouth behavior (Mertens et al., 2019).

A study made in Ethiopia found that, in pre rainy season from March to June there was a higher number of diarrheal cases than expected number which is known as diarrhea high risk periods (Azage et al., 2017). But in Senegal, a higher number of diarrheal disease was observed in rainy season (Thiam et al., 2017). According to Musengimana et al. (2016), November and May are known as diarrheal season in Africa as those months increase the spread of pathogen that leads diarrheal disease.

2.3.2 Relative humidity and diarrhea

According to Azage et al. (2017), relative humidity is strongly associated with extreme rainfall events, so the effect of relative humidity on diarrhea is depending on the relationship between increased rainfall and diarrheal incidence.

Aik et al. (2020) found positive association between relative humidity and diarrheal pathogen in first quarter in each year than in others quarter in Singapore. Study also revealed that increase in relative humidity can increase the number of bacterial pathogen in fresh fruits and vegetables as it is the origin of bacteria and increase the incidence of diarrheal disease (Aik et al., 2020). That highlights the importance of food hygiene for reducing bacterial contamination on food and thereby reduce the risk of diarrhea.

2.4 Infrastructure and resources

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Mukabutera et al., 2016). Evidence suggest that higher incidence of childhood diarrhea in males compared to females were observed in pre rainy season due to inadequate safe drinking water and proper sanitation facilities (Azage et al., 2017). The differences of diarrheal incidence occur between male and female children because boys are more active than girls and therefore will have a greater risk of coming into contact with the bacterial environment (Azage et al., 2017).

2.4.1 Water sources and quality

Mertens et al. (2019) found a strong relationship between temperature, rainfall and diarrheal risk where populations greatly rely on the surface water. A study carried out in Botswana found that rainfall and flood pulse influences surface water quality and increased the outbreak of diarrheal disease in flood pulse river system (Alexander et al., 2018). As it is thought that surface water can increase the risk of diarrheal disease compared to ground water but study in low and middle income countries found a strong link between the outbreak of diarrheal disease and heavy rainfall which contaminate ground water (Mertens et al., 2019).

Also, increased water level as a result of annual flood can contaminate water sources through the transport of pathogen which lead increasing amount of diarrheal outbreak (Wangdi & Clements, 2017; Zhang et al., 2019; Thompson et al., 2015). Study in Senegal fount that heavy rainfall may wash away pathogen that deteriorate water quality and leads to diarrhea (Thiam et al., 2017).

2.4.2 Sanitation and hygiene facilities

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to rural area of Senegal because of the fecal contamination in the rainy season due to unimproved sanitation system. But study in Rwanda found that high rainfall intensity can act as protective against diarrhea in children who used unimproved sanitation system compared to those who had better sanitation facilities (Mukabutera et al., 2016). It is because most of the unimproved sanitation facilities is located on hillside in Rwanda so that runoff can easily remove pathogen and reduce the risk of diarrhea (Mukabutera et al., 2016). Also, man made activities, like land coverage due to rapid urbanization, reduction of green space in mega cities and improper maintenance of sewerage system may contribute the causal pathway of pathogens and leads diarrheal disease (Das et al., 2017).

2.5 Knowledge gaps

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association between climatic factors (temperature, rainfall, flood, and relative humidity) and diarrhea.

Though only one study made in Bangladesh found strong association between temperature and childhood diarrhea and increased number of diarrhea cases after flooding, but as it is a reverine country and located in the tropical region, Bangladesh experienced different types of natural disaster almost every year due to climate change (Khatun et al., 2016). Also, Bangladesh has a tropical moonson climate which is catagorized as heavy seasonal rainfall, high temperature and high relative humidity. Due to the geographical pattern and tropical moonson climate, most of the rural areas in Bangladesh are more vulnerable to natural disasters like floods, cyclone, storm surges, sea level rise, extreme temperature and droughts etc. Due to facing this problem, Bangladesh ranked second most vulnerable country to natural disasters among Asian countries and ranked fifth most vulnerable country to climate change (Mahmood, 2012). About 80% of the total area of this country is at risk of flooding. Rising sea levels directly increase coastal flooding which increase the likelihood of storm surges. But this natural disasters not only affect rural areas in Bangladesh, people live in urban areas also suffer from this nearly every year. Urban cities and towns located at the coastal area or along with river area are the frontline of climate change and experienced severe damage such as increased urban floods, water logging, infrastructures damage etc. (Khatun et al., 2016).

These are the knowledge gaps which is taken into consideration in this study which will focus on food handlers food hygiene knowledge, attitudes and practices in Bangladeshi context.

3 Theoretical Framework

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maintain certain behavior (Marathe et al., 2016). From several health behavior models, Knowledge-Attitude-Practice (KAP) model is one of the most common model which is proposed by western scholars in 1950s (Fan et al., 2018). This model was developed for family planning and population studies in 1950s. Later, in 1960s and 1970s this model was used in Africa to understand family planning (Kilale, 2016). Nowadays this KAP model is widely used to assess health related knowledge, attitude and beliefs and health seeking behavior/ practices in the context of specific illness or treatment (Andrade et al., 2020; Kilale, 2016).

The assumption of KAP model is:

a) knowledge determine an individual’s attitudes and

b) attitudes determine an individual’s practices (Kwol et al., 2020).

KAP model divides human behavior into three consecutive processes: knowledge acquisition, attitude generation and behavior formation (Wang et al., 2020). KAP model form a base relationship between knowledge, attitude and practices because knowledge is the basis of behavioral change which will further continue through their attitude and practices (Fan et al., 2018). That’s why this KAP model is used in many survey studies to identify the basic knowledge, attitudes and practices of study participants on a specific topic (WHO, 2021; Khan et al., 2014). Several studies have used this KAP model to investigate the knowledge, attitudes and practices of food handlers in different contexts over the years (Kwol et al., 2020). Because the safety knowledge of food handlers plays an important role in determining their attitudes which empowers them to maintain their food hygiene behavior in disease control and prevention (Wang et al., 2020; Kwol et al., 2020).

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this model, semi structured or structured questionnaire is used to collect information which is applicable for both qualitative and quantitative research study in relation to KAP (Andrade et al., 2020).

Figure 1: The Knowledge-Attitude-Practice model

In this study, KAP model is used to investigate knowledge, attitudes and practices of food handlers about food hygiene to observe how food handlers knowledge influences their attitudes and how attitudes in turn influences their food hygiene practices for diarrheal and food-borne disease prevention and control.

In KAP model, knowledge, attitude and practice are main three domain. Knowledge refers participants understanding on a specific topic or what is known by the participants about the specific topic. Attitude refers participant’s belief or feeling about this topic and practice refers participant’s action on a specific topic based on their knowledge and attitude (WHO, 2021).

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Knowledge is participants own understanding on food hygiene and food handling. Attitude is participant’s beliefs or feelings on positive, negative and don’t know statements regarding food hygiene. Practice is participant’s action to maintain food hygiene.

For such type of survey study, target population need to be addressed very specifically and clearly to achieve study aim (Andrade et al., 2020). As this study investigate food handlers knowledge, attitudes and practices of food hygiene, so the target population is responsible person who handle and prepare food at home. By using KAP model, this study will find out what is known, belief and maintain by food handlers about food hygiene.

3.1 Advantage of KAP model

The advantage of KAP model is the KAP survey method is easy to conduct and the results of the survey is easy to interpret. This model makes correlation between knowledge-attitude-practices by describing the current knowledge, attitude and practices of target population. The KAP model is used to identify the problem on a specific topic in order to create effective intervention planning (WHO, 2021).

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3.2 Limitations of KAP model

The limitation of this model is that data is not always holistic and realistic. By using this model, KAP survey tries to assess people’s own knowledge of a specific issues which is not accepted by the anthropologist because they know that people perceptions of a disease can only be understand with their perceptions of health (Siltrakool, 2017). Another problem of this model is collecting data on practices (Kilale, 2016). Because it is difficult to identify participants reality in their practices. Also, this model only describes about participants practices but can not explain why and how to practice (Kilale, 2016).

4 Problem of statement

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According to WHO, 30-40% food-borne diseases results from home which is caused by mishandling of temperature, improper food storage and unhygienic food handling and preparations. As, household domestic kitchen is the first place which fight against diarrhea and other food-borne diseases ,so domestic food hadlers have to aware about the food hygiene principles for handling and preparing food. Individuals at home who is responsible for handling and preparing food should have informed about the safety guidelines of food hygiene to control the incidence of food-borne diarrhea. Because direct food contamination is related to the storage condition of food, cooking, washing utensils and overall hygiene practices which should be maintained by the food handlers at home. In Bangladesh still now, no study was done among domestic food handlers to assess their knowledge, attitudes and practices of food hygiene to reduce the risk of diarrhea and food-borne disease. Therefore, safe food handling at home is necessary to find out what is known by domestic food handler about food hygiene, what are they belief about food hygiene and what they do to maintain food hygiene.

5 Aim

The aim of this study is to explore the knowledge, attitudes and practices of food hygiene among food handlers in Bangladeshi homes located in urban areas exposed to climate change.

6 Research questions

Q1. What is the level of knowledge, attitudes and practices of food hygiene among domestic food handlers?

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Q3. Does the level of knowledge, attitudes and practices of food hygiene differ between food handlers with different educational background?

7 Methodology

7.1 Study location

The study was conducted in two major urban cities in Bangladesh; Dhaka city and Chittagong city. Dhaka is the capital of Bangladesh and it is the largest city where 14.7 million people live in an area of 1530.84 square kilometer. It is located in the Ganga delta region and the city is bounded by the Buriganga, Dhaleswari and Shitalakshay River (Shahid et al., 2016). Chittagong is the second large port city which is known as the major coastal city of Bangladesh. It is located beside the Karnaphuli River between the Chittagong Hilly Tracts and Bay of Bengal (Shahid et al., 2016). Nearly every year, the Dhaka and Chittagong city faces urban flooding due to extreme rainfall (Eich et al., 2015; Akter et al., 2017). Dhaka city exposed 2000 mm rainfall annually where 80% occur during the rainy season (Eich et al., 2015). Most often people in Dhaka and Chittagong city were exposed to urban storm waterlogging situation during the wet season (Eich et al., 2015; Akter et al., 2017; Khatun et al., 2016). Rapid urbanization and improper maintanance of drainage system was the main reason of this situation (Eich et al., 2015; Akter et al., 2017).

Also, temperature data indicates that these two urban cities were exposed to higher temperature than other cities in Bangladesh (Shahid et al., 2016).

7.2 Population

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7.3 Study design

A descriptive cross sectional study was conducted to perform this study. The reason for conducted cross sectional study was to compare different group of variables at the same time. Also, this cross sectional study could compare the different group of population at single point in time (Setia, 2016).

A self administered online questionnaire was designed in this study to address the aim of this study by involving a large amount of participants (Bresee, 2014). This method was used because it was easy to conduct than others study approaches in a limited time period. Others interview methods like, face to face interview was not done because it was relatively costly and difficult to invite and unite participants together in this present Covid-19 situation. Online questionnaire was used in this study because it was easy to conduct at this present time situation to access participants anywhere at anytime.

7.4 Questionnaire design

The questionnaire was developed according to the WHO recommendations for Five keys to safer food and WHO recommendations on Knowledge, attitudes and practices (KAP) survey guidelines (WHO, 2015; WHO, 2021). The questionnaire was presented in online in a Google Form and the medium of questionnaire was in Bengali. The questionnaire had multiple questions along with a consent statement. There were four sections of this questionnaire: a) socio demographic information, b) knowledge about food hygiene, c) attitude related questions on food hygiene, and d) practices related question on food hygiene.

7.4.1 Socio-demographic section

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water supply at home, how water stored at home and filtration method used for drinking water at home.

7.4.2 Knowledge section

The second section of the questionnaire included 10 questions regarding the knowledge of food hygiene. These 10 questions were answered by “right”, “wrong” and “don’t know” choices where 1 was scored for right answer and 0 was scored for wrong and don’t know answer. According to Bloom’s cut-off point, the score was categorized as good (80-100%), Moderate (50- 79%) and poor (less than 50 %). Reverse scoring was used for negative statements regarding food hygiene knowledge (Khan et al., 2014).

7.4.3 Attitude section

The third section of the questionnaire included 9 questions about attitudes toward food hygiene which were answered by “agree”, “disagree” and “don’t know” choices where 1 was scored for agree and 0 was scored for disagree and don’t know. Reverse scored was used for negative statements regarding attitudes towards food hygiene (Khan et al., 2014).

7.4.4 Practice section

The fourth section of the questionnaire included 13 questions regarding practices of food hygiene. According to Likert scale, the questions were answered by “totally disagree=1”, “disagree to some extent=2”, “agree=3” and “strongly agree=4” which was scored from 1-4 (Joshi et al., 2015). Reverse scoring was applicable for if there were any native statements regarding food hygiene practices.

7.5 Sampling technique

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7.6 Method for data collection

The questionnaire link was published on social media open groups, Facebook and E-mailed to the participants using contacts. The population size of this study was 3225 from which 3200 members were in Facbook open groups and questionnaire was send to 25 people by E-mail. From this population size, only 180 responses were collected from which maximum responses were from Facebook open groups and others were from E-mail contacts.

The participants were allowed to answer the questionnaire from 25th March to 15th April, twenty two days. In the middle of twenty two days, participants were get reminder message to fill the questionnaire.

7.7 Method for data analysis

The statistical package for social science (SPSS) software was used for data analysis.

7.7.1 Descriptive analysis

Descriptive analysis such as mean, standard deviation, Fisher exact test, chi square test, Maan- whitney test and Kruskal Wallis test were used to evaluate demographic variables in relation to knowledge, attitudes and practices of the study participants. This analysis allowed simple interpretation of data which help to present the raw data in a more meaningfull way (Creswell & Creswell, 2018).

Variables in this study were socio demographic characteristics, knowledge, attitudes and practices of study participants. These variables were collected using different scale.

Variables Type of Scale

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Gender Nominal scale, female=1, male=2, do not wish to identify myself=3

Education Nominal scale, SSC=1, HSC= 2, Bachelors degree=3, Master/M. Phill= 4, PhD= 5

Knowledge Nominal scale, right=1, wrong=2, dont know=3 Attitude Ordinal scale, agree=1,

disagree=2, dont know=3 Practice Ordinal scale, totally

disagree=1, disagree to some extent=2, agree=3, strongly agree=4

8 Ethical consideration

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Participation was voluntary and participants could withdraw his/ her participation at any time before submitting their responses. No personal questions were asked in the questionnaire which would revealed the identification of participants and no data was disclosed to anyone to maintain privacy and confidentiality. The author (student) and thesis supervisor were the only person to have access the data and no authorized person was able to see them. The results of this survey were presented as a group result, so it was not possible to identify the individual’s response.

9 Results

9.1 Descriptive analysis

A total 180 participants responded to participate in the KAP survey on food hygiene. One response was excluded from the analysis because the participants had not been ticking the box for ethical consent. 179 responses were included in the overall analysis where 170 responses completed without missing information and nine single items were missing in the questionnaire. From nine single items, one item was from demographic profile of the respondents, five items were from the knowledge related questions regarding food hygiene and three items were from the attitude section regarding food hygiene. No item was missing from the questionnaire regarding practices on food hygiene. Missing items on the questionnaire was presented in table 1.

Table 1: Single missing items on the questionnaire

Section Missing item question Number of item Demographic How many people live in your

home including you? 1 Knowledge Food contamination is caused by

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pathogenic microorganism

Food contamination can be detected by taking smell or taste 1 Attitude Jewelry (bangles, ring) and watch

can be worn during cooking 1 Frozen meat, chicken and fish can be defrosted in a bowl with warm water or left in the sink at room temperature

1

Habit of nail biting can contaminate food 1

9.2 Demographic data

The analyzable questionnaires were obtained from one hundred seventy nine respondents from two urban cities in Bangladesh, Dhaka and Chittagong. The demographic characteristics of survey respondents are listed in table 2. 63.9% (n=115) of respondents were from Dhaka, the capital city of Bangladesh while 35.7% (n=64) of respondents from Chittagong, the second mega city of Bangladesh. The percentage of female respondents were 74.3% (n= 133), male respondents were 24.4% (n= 44) and the percentage of those who did not wish to identify themselves were 1.1% (n= 2). Most of the participants were aged between 26-35 years old of a total 73 (40.7%), followed by participants who aged between 18-25 years old of a total 49 (27.3%), participants aged between 36-45 years old of a total 39 (21.7%), respondents aged between 46-55 years old of a total 13 (7.2%) and participants aged between 56-65 years old of a total 5 (2.8%).

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The majority of participants were housewife 38.3% (n=69) while 25.1% (n=45) participants were doing their study. Also, participants working in government/ private sector were 22.3% (n=40) and working in their own business were 13.3 % (n=24). Only 0.6% (n=1) participant was unemployed. The percentage of people live in a home range between 1-4 were 35.2% (n=63), 5-10 were 45.3% (n= 81), 11-16 were 3.4 % (n=6) and 16 to more than were 16.2% (n= 29).

Results also showed that maximum respondents main source of water supply at home is from WASA supply which were 93.85% (n=168), followed by from pipe water from municipality were 5 % (n= 9) and bought water were 1.1% (n=2) while the maximum percentage of water stored at their rooftop tank were 69.27% (n=124), followed by underground tank were 29.6% (n=53) and keep in bucket/vessel/container were 1.1% (n=2). No participants use river water as their main source of water supply at home.

Besides, 78.2% (n=140) participants used filter for drinking water filtration, 20.1% (n=36) used normal boiling method and 1.7% (n=3) did not use any filtration method. No participants used chlorine tablet for drinking water filtration.

Table 2: Demographic characteristics of respondents

Demographic characteristics Percentage Gender

•_Female •_Male

•_{Do not wish to identify}

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Marital status • Unmarried • Married • Widow •_Divorcee 33.5% (n= 60) 63.3% (n= 114) 1.7% (n=3) 1.1% (n= 2)

Living urban city

• Dhaka

• Chittagong 63.9% (n= 115) 35.7% (n= 64)

Educational level

• Secondary school Certificate

• Higher Secondary School Certificate • Bachelor’s degree •_{Masters/ M.Phill} •_PhD 8.3% (n=15) 21.1% (n=38) 40.2% (n=72) 27.2% (n= 49) 2.8% (n=5) Occupation • Studying • Working in govt./private sector

• Working in own business • Housewife • Unemployed 25.1% (n= 45) 22.3% (n=40) 13.3% (n=24) 38.3% (n=69) 0.6% (n=1)

People live in a home

• 1-4 • 5-10 • 11-16 • 16- more than 35.2% (n= 63) 45.3% (n=81) 3.4% (n= 6) 16.2% (n=29)

Main source of water supply

•_{WASA supply} •_{Pipe water from}

municipality • Bought water • River water 93.8% (n=168) 5% (n=9) 1.1% (n=2) 0% Water store •_{Underground tank} •_{Rooftop tank} •_{Keep water into}

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• Normal boiling • Chlorine tablet • No method use 20.1% (n= 36) 0% 1.7% (n= 3)

9.3 Food hygiene knowledge level of participants

Table 3: represents the knowledge of study participants in food hygiene. The knowledge level of study participants was grouped into three status, 8-10 points scores good, 6-7 points scores moderate and 0-5 scores poor which is measured by using the percentage level 80%-100%, 60%-70% and 0-50% respectively. From ten knowledge related questions, 141 (78.77%) participants answer were between the level of 80%-100% which mean good knowledge, 36 (20.11%%) participants answer were between the level of 60%-70 % which mean fair knowledge and 2 (1.11%) participants answer were between the level of 0-50% which mean poor knowledge. From this result, it is clearly shown that the study participants had good knowledge level in food hygiene.

Table 3: Knowledge of study participants in food hygiene Knowledge items Right Wrong Don’t

know Food contamination is caused by

pathogenic microorganism 86.0% 1.1% 11.7% Unprocessed food poses a high risk of

food contamination 96.0% 1.6% 1.6% Unwashed fruits and vegetables poses a

high risk of food poisoning 98.8% 0.5% 0.5% Well cooked food is free from

pathogenic microorganism 97.7% 0 1.6% Clean water and soap are the basic

requirements for hand washing 100% 0 0 Food contamination can be detected by

taking smell or taste 82.1% 15.0% 2.2% Leftover cooked food can be kept at

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Drinking water without proper boiling or filtration can poses high risk or poisoning

97.7% 1.1% 1.1%

Use same knife and cutting board for vegetables and meat can cause food-borne disease

75.4% 17.8% 6.7%

Foods are not safe to eat if they are not

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temperature whereas 62% participants answered “wrong” and 9.4% answered “don’t know” regarding this issue.

9.4 Food hygiene attitude level of participants

Table 4: represents the attitude of study participants toward food hygiene. As responses were categorized into three attitude levels, (80%-100%) good attitude, (60%-70%) moderate attitude and less than 60% low attitude, 40% (n=72) had good, 57.4% (n=103) had moderate and only 2.23 % (n= 4) had low attitude level in food hygiene. So, most of the study participants were moderate in their food hygiene attitude level.

Table 4: Attitude of study participants toward food hygiene Attitude related items Agree Disagree Don’t

know Defrosted food should not be

refrozen 78.9% 12.8% 8.3% After purchasing, egg must be

washed before being stored 96.6% 2.8% 0.6% Washing hand after sneezing/

coughing can reduce the risk of food contamination

98.9% 1.1% 0.6%

Hand washing should be done after touching hair, nose, mouth or other parts of the body during cooking and food handling

98.9% 1.1% 0

Raw food and cooked food should

be stored separately 98.9% 0.6% 0.6% Use of clean water for cooking and

washing purpose can reduce the risk of food contamination

98.9% 1.7% 0.6%

Jewelry (bangles, ring) and watch

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Frozen meat, chicken and fish can be defrosted in a bowl with warm water or left in the sink at room temperature

63.7% 27.4% 9.5%

Habit of nail biting can contaminate

food 92.7% 4.5% 2.8%

Out of 100%, 98.9 % participants agreed on few attitude related statements such as, “washing hand after sneezing/ coughing reduce the risk of food contamination”, “hand washing should be done after touching hair, nose, mouth or others part of the body during cooking and food handling”, “raw food and cooked food should be stored separately” and “use clean water for cooking and washing purpose can reduce the risk of food contamination”. Also, 96.6% participants agreed that egg must be washed before being stored and 92.7% agreed that nail biting habit can contaminate food while 2.8% and 4.5% participants disagreed these statements respectively. 78.9% participants accepted that defrosted food should not be refrozen while 12.8% disagreed the item and 8.3% even had no idea (answered “don’t know”) about this attitude related item. In addition, more than half of the study participants disagreed on two attitude related statements which were, “jewelry (bangles, ring) and watch can be worn during cooking” (60%) and “frozen meat, chicken and fish can be defrosted in a bowl with warm water or left in the sink at room temperature” (63.7%) while the percentages of participants agreement on these statements were 31.7% and 27.4% respectively which is very low. Also, 8.3% and 9.5 % participants had even no idea about these statements respectively.

9.5 Food hygiene practice level of participants

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good, 36-40 points= moderate and less than 36 points= poor. Out of 179 participants, 88.82% participants had good practice level in food hygiene which was between 41-52 points, 10.05% had moderate practice level in food hygiene which was between 36-40 points and 1.11% had poor practice level on food hygiene which was less than 36 points.

Table 5: Practices of study participants towards food hygiene Practice related items Totally

disagree Disagree to some extent

Agree Strongly agree I wash my hands with clean

water and soap before cooking and handling food

1.1% 1.1% 22.2% 77.2%

I wash my hand with clean

water and soap after toileting 0.6% 0 7.2% 92.8% I cover my mouth while

sneezing or coughing and then washing my hand

0 2.8% 30.6% 67.8%

I wash my hands after touching my face, nose, hair and other body parts while cooking or handling food

0.6% 16.7% 35% 47.8%

I use clean water to wash fruits and vegetables before eating

0 0 18.3% 81.7%

I use separate utensils for

raw food and cooked food 0 2.2% 21.7% 76.1% I check the expiry date of

foodstuffs when buying 0 0.6% 14.4% 85% I wash the utensils with

clean water and soap before cooking and while serving the meal

0 1.7% 27.8% 70.6%

I store meat, chicken in

freezer in a separate portion 0.6% 1.7% 22.8% 75% I always cover my hair

during preparing and handling food

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I drink water after boiling/

filtration it properly 0 0 15% 85% I keep food in kitchen and

fridge with proper covering 0 0.6% 22.2% 77.2% I avoid cooking or food

handling when my hand have cuts or wounds

4.4% 28.9% 32.2% 34.4%

More than half of the practice related questions were agreed by the study participants out of 13 questions such as, washing hands with clean water and soap before cooking and after toileting, covering mouth while sneezing/coughing and then washing hand, using clean water to wash fruits and vegetables, using separate utensils for raw and cooked food, checking expiry date of foodstuffs when buying, washing utensils with clean water and soap before cooking and serving meal, storing meat/ chicken in a separate portion of freezer, covering food properly in the fridge and kitchen and boiling drinking water properly. In addition, total more than half of the study participants disagreed on two practice related statements that they cover their hair during preparing and handling food (28.3%) and avoid cooking or food handling when their hand have cuts/wounds (33.3%). Also, 16.7% participants disagreed to some extent that they wash their hands after touching their face, nose, hair and other parts during cooking and handling food.

9.6 Difference between men and women food hygiene knowledge, attitude and practice level

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Mann- Whitney test was done to identify any attitude and practice level difference between men and women.

From the study results it was found that, there is no statistical difference in the food hygiene knowledge level between men and women. The findings of all variables values were greater than P-value <0.05 in relation to knowledge level which considered not to be statistically significant.

Table 6: Fisher Exact test to identify knowledge level difference in men and women Variables Fisher- Freeman-Halton Exact test (value) Exact Sig. (2 sided) Decision

Food contamination caused by

pathogenic microorganism 2.646 1.00 Insignificant Unprocessed food poses a high

risk of food contamination 4.264 0.831 Insignificant Unwashed fruits and vegetables

poses a high risk of food poisoning

6.252 1.00 Insignificant

Well cooked food is free from

pathogenic microorganism 4.349 0.183 Insignificant Clean water and soap are the

basic requirements for hand washing

A

Food contamination can be

detected by taking smell or taste 1.894 0.946 Insignificant Leftover cooked food can be

kept at room temperature more than two hours

Drinking water without proper boiling or filtration can poses high risk of poisoning

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*Note: a= no statistics are computed because clean water and soap are the basic requirements for hand washing is a constant.

Results also showed that, only one variable “Jewelry (bangles, ring) and watch can be worn during cooking” showed statistical difference in food hygiene attitude level between men and women. The value of this variable is 0.011 which is less than P-value <0.05.

Figure 2: Difference in mean value of men and women food hygiene attitude level

84.11 103.78

Jwelery (bangles, ring) and watch can be worn during cooking

Female Male

Use same knife and cutting board for vegetables and meat can cause foodborne disease

Foods are not safe to eat if they

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Table 7: Mann- Whitney test to identify attitude level difference in men and women Variables Mean±Std. Deviation Asymp. Sig. (2 tailed) value Decision

Defrosted food should not be refrozen

1.30 ± 0.615 0.410 Insignificant

After purchasing, egg must be washed before being stored

Washing hand after sneezing/coughing can reduce the risk of food contamination

1.01 ± 0.105

0.415 Insignificant

Hand washing should be done after touching hair, nose, mouth or others part of the body during cooking or handling food

Raw food and cooked food should be stored separately

1.02 ± 0.167 0.404 Insignificant Use of clean water for cooking

and washing purpose can reduce the risk of food contamination

Jewelry (bangles, ring) and watch can be worn during cooking

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Habit of nail biting can contaminate food

In addition results also showed statistical difference in food hygiene practice level between men and women. The significance values in food hygiene practice level between men and women were 0.033 for “I use clean water to wash fruits and vegetables before eating”, 0.016 for “ I use separate utensils for raw food and cooked food”, 0.002 for “I checked the expiry date of foodstuffs when buying”, 0.010 for “ I store meat, chicken in a freezer in a separate portion”, 0.002 for “ I always cover my hair during preparing and handling food”, and 0.023 for “ I keep food in kitchen and fridge with proper covering” which is less than P-value <0.05.

Figure 3: Mean value of food hygiene practices between men and women

79.35 77.11 76.19 76.07 69.84 78.06 92.19 92.93 93.24 93.28 95.34 92.62 0 20 40 60 80 100 120 clean water to wash fruits…

separate utensild for raw and… Check expiry date of… Store meat/ chickenin frezeer… Always cover my hair during… Keep food in kitchen and…

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Table 8: Mann- Whitney test to identify practice level difference in men and women Variables Mean± Std. Deviation Asymp. Sig. (2 tailed) value Decision

I wash my hands with clean water and soap before cooking and handling food

I wash my hands with clean water and soap after toileting

I cover my mouth while sneezing/ coughing and then washing my hand

I wash my hands after touching my face, nose, hair and others body parts while cooking or handling food

3.82 ± 0.389 0.033 Significant I use separate utensils for raw

food and cooked food

3.74 ± 0.490 0.016 Significant

I checked the expiry date of foodstuffs when buying

3.84 ± 0.379 0.002 Significant

I wash the utensils with clean water and soap before cooking and while serving the meal

I store meat, chicken in a freezer in a separate portion

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I always cover my hair during preparing and handling food

3.13 ± 0.908 0.002 Significant

I drink water after boiling / filtration it properly

I keep food in kitchen and fridge with proper covering

3.77 ± 0.438 0.023 Significant I avoid cooking or food

handling when my hand have cuts or wounds

9.7 Educational difference between food handlers food hygiene knowledge, attitude and practice level

For research question 3, (Does the level of knowledge, attitudes and practices of food hygiene differ between food handlers with different educational background?), Chi square test was done to identify the difference of knowledge level of food handlers based on their educational background and Kruskal- Wallis test was done to identify the difference of attitude and practice level of food handlers based on their educational background.

The study results found that there is no statistical difference on knowledge level of food handlers based on their educational background. All variables values were greater than p value (<0.05) in relation to knowledge level.

Table 9: Educational difference in knowledge level of food handlers Variables Chi- square Asymp. Sig.

(2-sided) Food contamination caused by pathogenic

microorganism

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*Note: a= no statistics are computed because clean water and soap are the basic requirements for hand washing is a constant.

Results also showed that in attitude level, only one variable, “Jewelry (bangles, ring) and watch can be worn during cooking” showed statistical difference with 0.014 value which is less than P- value <0.05.

Unprocessed food poses a high risk of food contamination

7.309 0.504

Unwashed fruits and vegetables poses a high risk of food poisoning

13.652 0.091

Well cooked food is free from pathogenic microorganism

4.599 0.331 Clean water and soap are the basic

requirements for hand washing

A

Food contamination can be detected by taking smell or taste

12.616 0.126

Leftover cooked food can be kept at room temperature more than two hours

7.485 0.485

Drinking water without proper boiling or filtration can poses high risk of poisoning

6.938 0.543

Use same knife and cutting board for vegetables and meat can cause foodborne disease

10.462 0.234

Foods are not safe to eat if they are not covered properly

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Table 10: Educational difference in attitude level of food handlers Variables Kruskal-

Wallis H

Asymp. Sig. Defrosted food should not be refrozen 2.243 0.691 After purchasing, egg must be washed before being

stored

5.400 0.249

Washing hand after sneezing/coughing can reduce the risk of food contamination

2.989 0.560 Hand washing should be done after touching hair,

nose, mouth or others part of the body during cooking or handling food

6.358 0.174

Raw food and cooked food should be stored separately

2.989 0.560

Use of clean water for cooking and washing purpose can reduce the risk of food contamination

2.194 0.700

Jewelry (bangles, ring) and watch can be worn during cooking

12.493 0.014

8.651 0.70

Habit of nail biting can contaminate food 4.443 0.349

*Note: a. Kruskal-Wallis test

b. Grouping variable: What is your level of education

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which showed statistical difference with 0.045 value which is less than P-value <0.05.

Figure 4: Educational difference in Food handlers mean value of food hygiene practices

Table 11: Educational difference in practice level of food handlers Variables Kruskal-Wallis H Asymp. Sig. (2 tailed) value I wash my hands with clean water and soap

before cooking and handling food

3.280 0.512

I wash my hands with clean water and soap after toileting

4.364 0.359

I cover my mouth while sneezing/ coughing and then washing my hand

4.259 0.372 90.07 78.12 86.35 99.77 137

I wash my hands after touching my face, nose, hair and others body parts while cooking or handling food

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I wash my hands after touching my face, nose, hair and others body parts while cooking or handling food

9.720 0.045

7.864 0.097

I use separate utensils for raw food and cooked food

1.376 0.848

I checked the expiry date of foodstuffs when buying

2.256 0.689

I wash the utensils with clean water and soap before cooking and while serving the meal

2.628 0.622

I store meat, chicken in a freezer in a separate portion

2.00 0.736

I always cover my hair during preparing and handling food

6.977 0.137

I drink water after boiling / filtration it properly 5.514 0.238

I keep food in kitchen and fridge with proper covering

6.182 0.186

I avoid cooking or food handling when my hand have cuts or wounds

5.027 0.285

*Note: a. Kruskal-Wallis test, b. Grouping variable: What is your level of education

10 Discussion

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in urban setting of Bangladesh. This study is one of the first kind of study conducted on knowledge, attitude and practices (KAP) about food hygiene among food handlers at urban household level in Bangladesh using the WHO “five keys for food safety” which is similar to a study conducted in India urban household setting using WHO five keys for food safety principle (Ganta & Kadeangadi, 2019). A self administered standard questionnaire was used as a data collection tool based on WHO “five keys for food safety” principle.

10.1 General information of study subjects

The present study explores the knowledge, attitude and practices of food hygiene among domestic food handlers at urban cities in Bangladesh. Knowledge, attitude and practices of food handlers at home were found to have good levels in this study. This is similar to the study conducted in Tehran among 95 food handlers of semi industrial catering in governmental organization based on WHO five keys to safer food (Fariba et al., 2018). The subjects of the study were 179 food handlers from two urban cities in Bangladesh, Dhaka and Chittagong who was responsible for preparing and handling food at home. The study used an online questionnaire with 41 questions which is divided into four sections: a) socio demographic characteristics, b) knowledge of food handlers c) attitude of food handlers d) practices of food handlers. As the study used descriptive analysis, so the sample size was good enough to analyze data and control the risk of false negative response.

10.2 Socio-demographic characteristics

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38.3% (n=69) followed by participants were studying 25.1% (n=45) and working in government and private sector 22.3% (n=40). This is similar to study in Nigeria, Kenya and Italy which also reported higher proportion of female’s involvement in food handling at home (Adebowale & Kassim, 2017; Abiga et al., 2017; Langiano et al., 2012). This is because Bangladeshi women from their marital and professional position were obliged to fulfill the responsibilities of household as their first traditional role, which include food preparation, food handling, home keeping etc.

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In addition, Bangladesh made tremendous progress in educational sectors from past decades. The literacy rate of Bangladesh is 74.70%. The education system of Bangladesh has three major levels: primary level (Grade 1-5, Grade 6-8), secondary level (Grade 9 and 10, Grade 11 and 12) and tertiary level (3 or 4 years of bachelors degree followed by 1 year masters degree and then specialized tertiary education known as PhD) (Chowdhury & Sarkar, 2018). The primary level of education provides basic education which was compulsory for children aged between 6-10 years. According to Chowdhury & Sarkar (2018) educational resources and facilities provided by the government to encourage children to complete primary level education. Thus, the dropout rate of primary education children was also decreased 2010 to 2016 (39.8% to 19.2%). The secondary level of education was the successive stages of students where they chose further study directions which helped them to get employment opportunities in their later life. In addition, to meet the demand of higher education currently 130 universities (both public and private) provided tertiary education nearly one million students across the country (Chowdhury & Sarkar, 2018).

In case of education, more than half of the study participants were in university level who were mostly Bachelor’s degree holder 40.2% (n=72) and Masters/ Phill degree holder 27.2% (n=49).

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In regards to number of people in a household, study in Kenya where household food handlers were 18 years or above showed that three to four people living together in a household influenced food hygiene and safety practices (Abuga et al., 2017). This finding is similar to this study results where majority of the household had five to ten people living together 45.3% (n=81) and had better food hygiene practices level (88.82%). A study carried out by Agustina et al. (2013) in Indonesia reported that household more than six members having 2.3 times higher risk of suffering from diarrhea due to poor food hygiene knowledge and unsafe practices. This contradicted to the present study results and supported Meysenburg et al. (2014) study result which showed that household having more people maintained food hygiene safety practices for the children or others aged people.

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practices and had good knowledge about the importance of water filtration to avoid diarrhea and other foodborne illness.

10.3 Food handler’s knowledge of food hygiene

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et al., 2012). This was similar to the present study result where approximately 98% of study participants had knowledge that well cooked food and having proper covering on food is free from pathogenic microorganism and high risk of food poisoning.

In the present study, 98.9% had knowledge on unwashed fruits and vegetables poses a high risk of food poisoning. This was similar to the study in India among urban food handlers where 96% participants knew that vegetables and fruits must be washed before cooking or eating (Ganta & Kadeangadi, 2019). Because, foods or meals prepared from unwashed vegetables might be contaminated with faecal contamination (Tomaszewska et al., 2018). Also, 75% participants had knowledge regarding using different knife and cutting board for vegetables and meat to avoid risk of foodborne disease which was similar to the study result in India, where 76.3% agreed on that statement. This could be because different knife and cutting board could reduce the risk of bacterial transfer from one raw food to another (Naeem et al., 2018). But many participants in Italian home reported that same knife and cutting board could be used for vegetable and meat (Langiano et al., 2012).

So, the knowledge of study participants was appropriately fit to the KAP model because knowledge refers participants understanding on a specific topic or what is known by the participants about the specific topic. In the present study, most of the participants had their own better understanding about food hygiene and food handling at their home.

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reported the same result regarding food detection and study in Nigeria where study participants reported that leftovers were safe to eat until they smell bad (Victoria et al., 2012; Eze & Anyaegbunam, 2014). But food contamination could not be detected via sensory verification because bacteria causing food poisoning did not change the color, smell or taste of the food. Actually, the bacterial growth on the leftover food increased after cooking when the temperature of the food gradually down (Eze &Anyaegbunam, 2014).

Surprisingly, the study revealed that there was no significant difference between men and women food hygiene knowledge level and no significant difference among food handlers food hygiene knowledge level based on their educational level. This was opposite from the study in Poland and Thailand where Polish women had better food hygiene knowledge than men and similar to the study in Nigeria where no significant difference was found among food handlers knowledge level based on their educational level (Tomaszewska et al., 2018; Odo & Onoh, 2018).

10.4 Food handlers’ attitude of food hygiene

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level towards food hygiene despite having good food hygiene knowledge level.

In attitude section, 98.9% participants agreed that frequent hand washing after touching different body parts during cooking and handling food is necessary. This was similar to the study in India where household female food handlers reported that hand washing was necessary during food preparations (Ganta & Kadeangadi, 2019). Also, a study in India among food handlers found faecal bacteria as a result of improper hand washing in the nails of the study participants (Malhotra et al., 2006). The result of Malhota et al. (2006) study supported the present study result where 92. 7% agreed that habit of nail biting can contaminate food.

In addition, Teh et al. (2016) reported that due to improper food storage and inappropriate temperature handling 45.65% foodborne disease results while food preparations and handling. In the present study, 98.9% and 96.6% participants agreed that raw food and cooked food should be kept separately and egg must be washed properly before being stored. This could be because toxic effect from raw food could come into contact with cooked food and increased the chance of foodborne disease. Also, many foodborne cases were results from the poultry raw eggs (Naeem et al., 2018). Authors also reported that eating raw egg without proper washing hospitalized many food handlers in Pakistan (Naeem et al., 2018).

Degree project, 30 credits

Food hygiene knowledge, attitudes and practices of

food handlers in Bangladeshi homes