COVID-19 knowledge, attitude, practices, and associated factors among Bangladeshi food handlers from various food industries

Abstract

Background and objectives

It is believed that preventive safety measures are the most effective way to avoid the COVID-19. The adherence of workers to these measures is largely determined by their knowledge, attitude, and practices (KAP). Because they are in close proximity to consumable items, workers in the food industry must be especially vigilant during this period. The purpose of this present study was to evaluate the COVID-19 knowledge, attitudes, and practices of food handlers in different food industries of Bangladesh.

Study design

This was a cross-sectional study.

Methods

This included the participation of 400 food handlers from 15 food industries. The information was collected from the participants through a questionnaire prepared in Google form. Different nonparametric tests and a linear regression model were performed for statistical analysis.

Results

With a correct response rate of about 90% on average (knowledge 89.7%, attitude 93%, practices 88.2%), the participants showed an acceptable KAP (>80% correct response) regarding COVID-19. Education (p = 0.00) and working experiences (p = 0.01) had a significant association with the total KAP scores.

Conclusion

Food handlers in the food industries of Bangladesh have adequate knowledge, a positive attitude, and the desired practices regarding the COVID-19 issue.

Graphical abstract

Highlights

• •This is the first KAP study considering the food industries in Bangladesh and the global pandemic COVID-19.
• •The KAP of food handlers from various food industries in Bangladesh regarding COVID-19 were evaluated.
• •The KAP scores of participants regarding COVID-19 were satisfactory.
• •Education and working experience are associated significantly with the total KAP scores.
• •Further KAP studies are suggested in different commercialized industries in Bangladesh.

1. Introduction

Coronavirus disease 2019 (COVID-19) is regarded as one of the most pervasive pandemics since long. Due to its high transmission rate and uncommon infection characteristics, it has become a global public health threat. The World Health Organization (WHO) declared it a global health emergency after the first case was identified in Wuhan, China, in December 2019 [1]. Since the first case was identified on March 8, 2020 in Bangladesh, this disease has already claimed lives. The economy of Bangladesh is mostly dependent on the processing and manufacturing industries, and the majority of the population subsists on daily income. Nevertheless, ‘working from home is not a feasible option for food processing or any other manufacturing industry [2]. For avoiding the risk of food shortage, the highest priority should be given to supply chains [3]. Therefore, it is necessary to ensure the health and safety of food handlers by providing high importance on maintaining physical distance in manufacturing facilities [4]. In addition, Jubayer et al. (2020) outlined precautions to take when handling food during a pandemic, such as cleaning and disinfecting the entire complex with a 1% sodium hypochlorite solution, creating floor markers, providing adequate personal protective equipment (PPE), increasing cleaning and sanitization, and conducting regular health checks, among others [5].

In addition to food safety, manufacturers should include coronavirus prevention and control measures within their plants [6]. The SARS-CoV-2 is not a foodborne disease, as there is no evidence of transmission through any food product [4,7]. However, respiratory viruses are not transmitted through food. Even so, transmission is possible if an infected person touches the food, sneezes or coughs on it, and then another person touches the food or swallows it [3,8]. Consequently, the management of every food manufacturing industry must ensure the careful handling of foods and packaging materials, as well as proper personal hygiene, including thorough hand washing and sanitization. As precautionary measures, the Food and Drug Administration (FDA) suggests cleaning and sanitizing food contact surfaces prior to production [9]. Therefore, it is possible for workers to become infected with the virus via contact surfaces and the surrounding environment.

People must follow the control measures of WHO in order for this coronavirus disease (COVID-19) to be successfully controlled [10]. The success of implementing preventive measures is mostly dependent on the knowledge, attitude, and practices of an individual [11,12]. Several studies revealed that the prevention of the previous SARS outbreak was partially influenced by the public's knowledge and attitude of infectious diseases [13,14]. However, three and half years after the onset of the pandemic, there are very few credible studies or reports on food handler or relevant personnel safety, food safety, and actions implemented in the food and agriculture sectors of Bangladesh [5,15]. To enable and facilitate COVID-19 management within Bangladesh's food industries, we feel compelled to comprehend and assess whether the current state of workers' awareness and knowledge of the disease at this critical juncture is sufficient or if additional steps are required to bring it to a satisfactory condition. As a result, the current study was conducted to investigate the current state of COVID-19 related knowledge, attitude, and practices (KAP) and the associated factors influencing the KAP status of food handlers from various food industries throughout Bangladesh. The findings may help public health professionals and practitioners develop targeted strategies for implementing such studies in other industrial sectors and taking appropriate actions based on KAP studies.

2. Methods

A few supporting details have been added to the ‘supplementary information’ section to aid comprehension of this method section.

2.1. Study design

A cross-sectional study was carried out among 400 food handlers in fifteen (15) food industries all across Bangladesh between November 20, 2020, and February 20, 2021. We selected participants from the production, quality assurance (QA)/quality control (QC), store, maintenance, and human resource management (HRM) departments to participate in this survey. The inclusion criteria for the study were, a) being a Bangladeshi resident, b) having internet access, and c) participating voluntarily. Those who satisfied the inclusion criteria were invited to participate in the survey. The line managers also assisted us in prioritizing the participation selection. The infinite population formula was used to calculate sample size [S = (Z) [2] × P × (1-P) ÷ (M) [2]]. A 95% confidence level was used to calculate the Z-value (1.96). The population proportion (P) and margin of error (M) were calculated at the 50% (0.50) and 5% (0.05) levels, respectively.

2.2. Procedure

For avoiding close contact with the respondents, we decided to design a web-based questionnaire. A structured questionnaire (Bengali and English) was prepared online (Google forms), and the link was sent to the respondents through email and social media (Whats App and Facebook messenger). The questionnaire was pilot-tested for readability and clarity. Prior to being placed into a spreadsheet, cleaned, and subjected to principal component analysis, it was pilot-tested for face validity and then amended for reliability. In the first part, respondents were required to fill information designed to gather demographic data. The second part was on the knowledge, attitude, and practices regarding COVID-19. The knowledge part was divided into two parts, namely, general COVID-19 knowledge (10 questions) and knowledge related to food safety (10 questions). The attitude and practices part was comprised of 10 questions each. Questions from the KAP section were answered as true/false/don't know, agree/disagree/not sure, yes/no/didn't remember basis, respectively. A correct and desired response received one point, and the wrong or undesired answer received zero point. For the determination of adequate knowledge (>80%, score>16), positive attitude (>80%, score>8), as well as desirable practices (>80%, score>8), Bloom's cut-off point of 80% was utilized [5,16].

2.3. Statistical analysis

SPSS version 16.0 was used for statistical analysis. KAP scores of respondents are presented as mean and standard deviation. Categorical variables are computed as percentages. A linear regression model has been performed to determine underlying factors that enhanced KAP scores. The primary analysis of data showed non-normality in the sktest and Shapiro-Wilk test; hence we have used nonparametric alternative tests, namely, Mann-Whitney U test, Wilcoxon W test, and Kruskal-Wallis H test. In the regression model, gender is a dummy variable; age and experience are continuous variables, and the education and work area belong to categorical variables.

3. Results

3.1. Demographic characteristics

The demographic characteristics of participants are shown in Fig. 1. The mean age of the respondents was 32.9 ± 8.5, with the majority being male. Most of them were aged between 30 and 40. Almost everyone (93.5%) had some level of education, among which the maximum percentage (41.7%) was in the secondary education group. The rest had university and technical education. The majority of respondents (46.2%) had between two and five years of work experience, while the fewest (10.5%) had more than ten years of experience. While no one was found to be unaware of the situation, 54.7% of respondents acknowledged social media as a source of information about the COVID-19.

Fig. 1.

Demographic characteristics of respondents.

3.2. Knowledge, attitude, and practices of respondents

In this section, the percentage of accurate responses is derived by summing the average percentage of correct answers, and the KAP score is calculated in the form of mean ± SD (Table S1-Table S3). About 89.7% of respondents provided the correct answer with a knowledge score of 17.9 ± 0.08 (Table S1). Questions regarding general COVID-19 knowledge received 91.6% accurate responses, while food safety questions received 87.9% correct answers. Less than 80% of the replies were accurate in determining whether the coronavirus can survive freezing temperatures or whether UV light can eradicate it. About two out of every ten workers were unable to answer questions about comorbidity risks or zoonosis and were unaware of any registered medication on the market. With a score of 9.3 ± 0.04, more than 90% of people expressed a positive attitude towards different COVID-19 issues (Table S2). Over 10% of participants did not believe they could be affected while at work, and a similar proportion did not wish to receive training on COVID-19. Nearly 13% of respondents disagreed that washing hands for at least 20 s is necessary. The food handlers also demonstrated desirable outcomes in their practices. Table S3 reveals that nearly 90% of food handlers with a score of 8.8 ± 0.07 provided correct responses during their practice. Approximately 88% of workers exhibited excellent and proper conduct throughout the pandemic. However, nearly 20% of workers did not follow some guidelines, such as avoiding crowded areas, not touching their eyes, nose, or mouth when handling food, and avoiding public transportation (Table S3).

Scores on knowledge, attitude, and practices have been tested by different demographic characteristics, i.e., gender, age group, education, experience, work area in the current company, and source of information on COVID-19 (Table 1). In the case of knowledge, all demographic characteristics showed significant differences in central tendencies for each distribution. Other than the gender and field of work, all demographic characteristics showed significant differences in attitude (significant at 1% and 5% level of confidence). Education was the only factor that showed a significant difference (significant at 1% level of confidence) in the test for KAP scores. Therefore, the demographic characteristics lead to varying the individual score, while education possesses significant results in all three KAP elements.

Table 1.

Differences in KAP scores according to the demographic characteristics.

Variables	Characteristic	Knowledge			Attitude			Practices
		Score, M ± SD	U	W	Score, M ± SD	U	W	Score, M ± SD	U	W
Gender	Male	18.6 ± 0.01	850.3***	2231.46***	9.4 ± 0.01	2652*	8005*	8.8 ± 0.01	2674*	4053*
	Female	17.5 ± 0.03			9.3 ± 0.01			8.8 ± 0.01
			H			H			H
Age (years)	≤20	17.5 ± 0.33	72.7***		8.3 ± 0.08	9.287**		8.5 ± 0.10	2.221*
	20–30	18.8 ± 0.01			9.4 ± 0.02			8.8 ± 0.01
	30–40	17.4 ± 0.02			9.4 ± 0.01			8.8 ± 0.01
	≥40	18.5 ± 0.05			9.3 ± 0.03			8.9 ± 0.04
			H			H			H
Education	No schooling	13.8 ± 0.14	54.130***		7.4 ± 0.06	32.988***		6.5 ± 0.05	70.008***
	Secondary	18.2 ± 0.02			9.3 ± 0.03			8.7 ± 0.01
	Higher secondary	18.3 ± 0.01			9.5 ± 0.02			9.1 ± 0.00
	University	19.3 ± 0.03			9.6 ± 0.05			9.0 ± 0.03
	Technical education	18.8 ± 0.02			9.4 ± 0.03			9.0 ± 0.01
			H			H			H
Experience (years)	≤2	18.6 ± 0.03	66.952***		9.3 ± 0.03	8.534**		9.0 ± 0.03	3.181*
	2–5	18.5 ± 0.02			9.3 ± 0.01			8.8 ± 0.01
	5–10	17.0 ± 0.03			9.5 ± 0.02			8.9 ± 0.02
	≥10	17.2 ± 0.12			8.9 ± 0.04			8.7 ± 0.05
			H			H			H
Field of work in current company	Production	18.2 ± 0.02	65.09***		9.2 ± 0.01	8.8989*		8.7 ± 0.01	0.81*
	QA	17.7 ± 0.04			9.7 ± 0.03			8.9 ± 0.00
	Store	17.2 ± 0.10			9.1 ± 0.04			8.7 ± 0.05
	Maintenance	17.2 ± 0.08			9.4 ± 0.05			8.7 ± 0.05
	HRM	17.0 ± 0.08			9.4 ± 0.05			8.7 ± 0.05
			H			H			H
Source of information	Television and newspaper	17.4 ± 0.03	69.404***		9.5 ± 0.01	13.46***		8.8 ± 0.01	0.770*
	Social media	18.4 ± 0.02			9.2 ± 0.01			8.9 ± 0.01
	Websites	17.5 ± 0.05			9.2 ± 0.05			9.1 ± 0.01
	Family and friends	17.2 ± 0.13			8.8 ± 0.04			8.8 ± 0.06
	Unheard	0			0			0

***Significant at 1% level of confidence; **Significant at 5% level of confidence; *Significant at 10% level of confidence. M, mean; SD, standard deviation; U, Mann-Whitney test; W, Wilcoxon test; H, Kruskal-Wallis Test.

Other than the individual score on KAP elements, in the regression model, we have determined underlying factors that enhanced the total KAP score. The R-square value indicates the global check for the model that the model explains 81.4% of the variance in total score on knowledge, attitude, and practices (Table 2). A R-square value of 81.4% indicates that the model's independent variables explain 81.4% of the variance in the dependent variable. The R-square and F value (155) indicate that the model fits the data well. In this regression model, education and experience are significantly associated with the knowledge and practices of COVID-19. Age, gender, and work area had no significant association with the knowledge, attitude, and practices towards COVID-19. Those who attended primary school had 7.5 times more knowledge of COVID-19 than those who did not attend school, and it was 6.8 times higher for those who attended a high school, 7.5 times higher for those with a university degree, and 6.6 times higher among technical education holders than non-school-attending participants. The experience was also statistically significant at a 5% level of confidence, but unexpectedly the coefficient was negative in value, although very minimal. That indicates the younger to be more cautious or knowledgeable about COVID-19 than the older employees.

Table 2.

Regression on total KAP scores.

Variables	Demographic status	Coefficient	p-value
Constant		21.2***	0.00
Gender		−0.2***	0.6
Age		0.1**	0.4
Education	(Base-No Schooling)
	Primary	7.5***	0.00
	Higher Secondary	6.8***	0.00
	University	7.5***	0.00
	Technical Education	6.6***	0.00
Experience		−0.6**	0.01
Field of work	(Base- Production)
	QA	−0.1	0.7
	Store	−0.03	0.8
	Maintenance	−0.004	0.8
	HRM	−0.6***	0.3
R-Square = 81.4%; F-value = 155; Prob > F = 0.00

***significant at 1% level of confidence; **Significant at 5% level of confidence. p-value< 0.05 means we can reject the nulls, hence for both cases the central tendencies of both distributions differ.

4. Discussion

In the supplementary section, we present several actual outbreaks of COVID-19 in several food processing plants [17]. From the perspective of Bangladesh, a densely populated and lower-middle-income country, social distancing is visibly impossible [18]. At different stages of supply chain, COVID-19 is likely to have varying effects on the food and beverage industries worldwide. The food industries of Bangladesh are no exception. The primary concern of the food industry is to maintain the health and availability of its workforce [19]. Food handlers are usually exposed to various biological materials [20]. Moreover, the coronavirus can persist in the food industry's regular handling surface, e.g., metal, plastic, and glass, for a couple of days [21]. To prevent the spread of COVID-19, it is necessary for workers to have knowledge and a willingness to adhere to proper safety procedures.

According to our knowledge, this is the first study to evaluate the KAPs of food handlers in the food industry in relation to the COVID-19 pandemic in Bangladesh. However, since the outbreak, numerous studies on KAPs and COVID-19 have been observed [11,12,[22], [23], [24], [25], [26], [27], [28], [29], [30]]. In this study, respondents (almost 90%) from these food industries possessed adequate knowledge of COVID-19. General and food safety knowledge sections were responded correctly by 91.6% and 87.9% of participants, respectively. In a number of recent studies by Ref. [25] (93.2%) [12], (90%) [26], (89.5%) [27], (89%) [28], (86.9%) [24], (82.4%), greater than 80% of respondents exhibited similar levels of COVID-19 knowledge. These research were conducted on Chinese residents [12], healthcare professionals from Uganda [24], Pakistan [25], and China [27], as well as medical personnel in Chinese psychiatric hospitals [26]. All these industries from this current study have different certifications, such as ISO, HACCP and HALAL, and so on, and they need to arrange food safety training for all of their employees on a regular basis. This may be one of the causes for their food safety knowledge performance. Although there are no studies on COVID-19 and food industries, we found in the present study that the food safety knowledge of food handlers from various Bangladeshi food industries was commensurate with some relevant studies [[31], [32], [33]].

Almost nine out of ten people are typically aware of the causative organism, its symptoms, severity, and consequences, as well as its mode of transmission. Comparatively, few people were aware of whether this disease can transmit from pet animal to human. Due to the spread of panic and false information during the pandemic, many owners and individuals fear that their pets may transfer the disease to them. There is no substantial evidence of a considerable hazard posed by pets or animals [34]. Generally, participants with no education exhibited a lack of knowledge. People who learned about COVID-19 from family and friends were also somewhat ignorant. In the socio demographic condition of Bangladesh, many workers working in these food industries lacked education, financial security, and access to the internet and smartphones. Regarding COVID-19 information, they rely heavily on the opinions of others. As a result, they lacked knowledge of a number of crucial facts.

COVID-19 and food safety had a lower correct responses (87.9%) than the remainder of the knowledge section (91.6%). More than 25% failed to answer the question regarding the survival of SARS-CoV-2 in freezing temperatures. According to the WHO, this organism can survive at −20 °C for nearly two years, and transmission via frozen food can be possible [10]. According to a study, there is a significant knowledge gap regarding the incubation and transmission characteristics of this virus among Bangladeshis of various occupations [35]. Regarding the relationship between freezing temperature and microorganisms, a number of studies have demonstrated that food handlers have limited knowledge [31,[36], [37], [38]]. But the people in this study know more about this topic than the people in these studies. Usually, for the inactivation of viruses, a typical cooking temperature of more than 70 °C is sufficient [39]. The workers knew that cooking and heating is enough for the product to make it safe from pathogens. The SARS-CoV-2 cannot spread through drinking water. Commonly used treatment methods are competent enough to make the water safe [40], and it was known to almost all workers. Many of the respondents don't know if the virus can live in freezing temperatures or if UV rays can kill it. But a fair number of workers got the questions right about how pasteurization affects the coronavirus.

We discovered that the majority of respondents held a favorable attitude towards COVID-19. About 10% believed that industries should continue to operate during the COVID-19, and they would not get infected while working. In a country like Bangladesh, a worker's socioeconomic circumstances and obstacles may compel him/her to work while ill. As a result of the closure of industries in Bangladesh during the lockdown, a sizeable number of people lost their jobs [41]. Surprisingly, 7 in 10 participants said they usually made contact with eyes, mouth, and nose while handling food products in the production line. This unexpected behavior of not washing or sanitizing hands after coughing or sneezing and touching the face, nose, and eyes can also be observed in a study [42]. It was determined that the participants know the risks of touching the face during this time, but such strict practices may take some more time to be applied. Furthermore, there is a chance that they will consider themselves less susceptible to the transmission [43]. In another study from Bangladesh by Ref. [44], it was observed that nearly 30% of the participants frequently go outside and meet their friends. On the contrary, many improved practices in avoiding crowds can be seen in different study groups from Malaysia [30], China [12], and Iran [28]. In this study, however, a notable number of workers were found to go outside more than once (25.2%), not wear masks outside (about 13%), and frequently use public transportation. This kind of occurrence can force the business to close immediately [6].

According to the study, the total KAP scores were not affected by gender, age, and working sections, although there were differences in the knowledge scores. The knowledge scores of male participants, those aged 20–30 years, and employed in production departments were significantly higher. When, in most of the recent KAP studies [12,24,29,30,44] female participants showed higher scores than male. In different studies, individuals of different age limits demonstrated varying levels of knowledge. It is difficult to compare these results to those in the food industry due to their distinct working environments. For instance, respondents over 40 and 50 years of age possessed superior knowledge compared to respondents of other ages [22,30]. Another study found that respondents between the ages of 18 and 30 performed better on the COVID-19 knowledge-related questions [29].

The exciting thing is that the respondents with less experience were superior in their total KAP scores. It is a novel virus, and the young have more access to the internet and other information due to being technologically sound. A similar kind of result was observed by Huynh et al. [22]. Contradictory results can also be seen in a study, where participants with more experience had a higher level of knowledge [44]. Education showed to have a significant role in the KAP scores of the participants. This finding is in line with different studies [12,24,29]. Following television and newspapers as sources of the most recent COVID-19 information were websites, family and friends. Those who utilized social media to maintain their knowledge had significantly more information than others. In contrast to viewers of television and readers of newspapers, social media users were less optimistic. In this era, differences in age and level of education may be crucial considerations when deciding which media to use as a source of information [24].

Although there are not a large number of studies on COVID-19 KAP and food handlers around the world, we were able to find some studies from Pakistan [45], Jordan [46,47], and Malaysia [48] that can be compared to the present one. The study from Pakistan [45] and Malaysia [48] revealed a fair level of KAP among food handlers, which is somewhat consistent with the current research. However, research from Jordan revealed a low level of KAP among food handlers, including those in the dairy industry [46,47]. Similar to our study, education [45,48] and job experience [45] influence the KAP score of the respondents.

5. Study limitations

COVID-19 is a novel virus that was discovered just before the year 2020 began. Due to the absence of ample KAP studies in the food industries, interpreting the results was challenging. As this was an online study that utilized self-reported data, there is a possibility of respondent bias. It would be more beneficial if we could track the evolution of their KAP over time.

6. Conclusion

The article addresses a topic that may be of great interest to workers, consumers, processing plant managers, as well as the evolution of public health systems. The findings indicate that food handlers in Bangladeshi food industries have adequate knowledge, a favorable attitude, and the desired practices regarding the COVID-19 issue. Education and work experience were found to positively influence the KAP. It is essential to recognize the significance of hiring employees with a higher level of education and providing regular training. A KAP study could be utilized to determine the efficacy of any COVID-19-related training for industry personnel. In the context of Bangladesh, more research on the COVID-19 KAP should be conducted among food handlers in restaurants, street-food shops, and small- and medium-sized enterprises (SME), as people in this country tend to purchase food from these sources more frequently. In addition, additional research could be conducted to determine the KAP differences and significance of training between trained and untrained workers in various food industries. The current research will hopefully aid researchers and policymakers in developing strategies and implementing the necessary control measures.

Ethical consideration

The ethical committee of Sylhet Agricultural University, Sylhet-3100, Bangladesh checked and approved the study design. Respondents were also asked to provide informed consent. As it was an anonymous online survey, no personal information was used during the study. That is why ethical consent was not required for this study. All data were kept on a password-protected computer that was only accessible to the research team.

Data availability statement

Data will be available upon reasonable request.

Funding information

There has been no funding and financial support for this study.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

The following is the Supplementary data to this article: