Knowledge, Attitude, and Food Safety Practices among Street Food Vendors at a Metropolitan District in Ghana: A Cross-sectional Study

Background Street food is a vital component of cities and towns in developing countries. However, food poisoning has been associated with inadequate knowledge of food safety practices and inappropriate food handling. We examined the knowledge, attitude, and practices of street food sellers in the Takoradi Submetropolis, Ghana, on food safety and hygienic practice. Method In this descriptive cross-sectional study, 406 street food vendors were recruited based on a simple random sampling technique from the Sekondi-Takoradi Metropolis, Ghana, using a structured questionnaire. Data collected were analyzed with the chi-square test and binary logistic regression using Stata (version 16) software. Statistical significance was set at p < 0.05. Results The level of knowledge was low among 70.4% of the food vendors, and 51% had negative attitudes towards food safety and hygiene. Food hygiene practices were also poor among 52.3% of the participants. The predictors of low knowledge level were senior high (aOR = 0.37, 95% CI (0.19-0.70), p = 0.002) and junior high education (aOR = 0.52, 95% CI (0.27-0.99), p = 0.047). Having senior high education (aOR = 0.37, 95% CI (0.17-0.82), p = 0.014), prior training on food safety and hygiene (aOR = 0.50, 95% CI (0.29-0.84), p = 0.010), and having high level of knowledge (aOR = 0.33, 95% CI (0.20-0.54), p = 0.001) were associated with lower likelihood of negative attitude towards food safety and hygiene. Moreover, having junior high education (aOR = 6.20, 95% CI (2.78-13.87), p = 0.001), high level of knowledge (aOR = 4.70, 95% CI (2.77-7.98), p = 0.001), and positive attitude towards food safety and hygiene (aOR = 1.76, 95% CI (1.08-2.87), p = 0.023) were associated higher odds of good food practice. Conclusion Knowledge and attitude regarding food safety and hygienic practices was poor among street food vendors. Future initiatives should focus on establishing training programs for food vendors within the metropolitan assembly to improve their knowledge on food safety and hygienic practices.


Introduction
Food safety and hygiene are global health concerns, particularly in low-and middle-income countries (LMICs), due to the increasing prevalence of foodborne infections and associated mortality [1].Food safety is a major concern, with outbreaks of foodborne illness costing individuals, the food industry, and the economy significantly [2].Despite efforts by governments in these LMICs to promote food safety, the prevalence of foodborne disease remains a significant health hazard in both industrialized and developing countries [2].According to the WHO, 600 million foodborne diseases (FBDs) occur each year as a result of poor food safety and hygiene practices [3].This results in 420,000 deaths, the majority of which are due to meat-related vulnerabilities [3,4].In the United States, approximately 76 million FBDs resulted in 325,000 hospitalizations and 5000 deaths [5].In Ghana, FBDs kill approximately 65,000 people each year, including 5000 children under the age of five [1,6].According to a recent survey, a total of 1914 Ghanaians experienced various types of food poisoning between 2013 and 2021 [7].Moreover, about 60 cases from 36 facilities resulted in 36 patients losing their lives [7].Enterobacter, Citrobacter, Klebsiella, Shigella, and Escherichia coli have been identified as the most prevalent foodborne pathogens in Ghanaian street-vended food [8].Previous studies have also reported mesophilic bacteria and Enterobacteriaceae above acceptable levels in ready-to-eat street-vended foods in Ghana [9,10].Given that the majority of LMIC inhabitants depend mainly on street foods, the role of the street food sector cannot be undermined.
The street food sector plays a critical role in satisfying the dietary needs of commuters and urban dwellers in many developing-country cities and towns, feeding thousands of people every day with a diverse choice of dishes that are relatively inexpensive and easily accessible [6,11].However, many of these street foods do not satisfy basic hygienic stan-dards, which can result in morbidity and mortality from foodborne illnesses, as well as associated repercussions on trade and development.The main causes of contamination of ready-to-eat foods are the use of conventional processing techniques such as grinding and milling, improper holding temperatures, and inadequate personal hygiene on the part of food handlers [11].Moreover, the food is not sufficiently shielded from dust and flies [11].Street food in Ghana is primarily made and processed by hand and sold to the public at various lorry terminals, by the roadway, or by itinerant sellers.Most of these roadways and truck terminals are usually choked with dirt, which predisposes the food to flies.
Ghana is a developing nation renowned for its delicious, appealing, and varied street cuisine.In addition to satisfying the appetites of locals like those in the Takoradi Submetropolis of the Sekondi-Takoradi Metropolitan Assembly (STMA), Ghana's abundance of delicacies also piques the interest of tourists.Although there have been a considerable number of episodes of food poisoning linked to street meals in recent years [12], there is paucity of data regarding food safety and hygiene practices among street food vendors with 2 International Journal of Food Science STMA.Therefore, this study assessed the street food vendors' knowledge, attitudes, and practices regarding food safety and hygienic practices in the Takoradi Submetro of the Sekondi-Takoradi Metropolitan Assembly, Ghana.

Materials and Methods
2.1.Study Design.This study employed a descriptive crosssectional design to assess the knowledge, attitude, and practice of food safety and hygiene among street food vendors in the Sekondi-Takoradi Metropolis in August 2022.

Study
Site.This study was conducted in the Takoradi Submetro of the Sekondi-Takoradi Metropolis in the Western Region of Ghana.The submetro has four communities (Chapel Hill, New Takoradi, Takoradi, and Beach Road) under it and serves as a conduit between the residents of the various towns.
Sekondi serves as the administrative centre for the Sekondi-Takoradi Metropolitan Assembly (STMA), which is situated in the south-most portion of the Western Region.Mpohor District, Shama District, Effia-Kwesimintsim Municipal, and the Gulf of Guinea form its northern, eastern, western, and southern boundaries, respectively [13].With an entire area of 189 km 2 , the STMA is about 130 and 280 kilometers from Accra and La Cote d'Ivoire, the east, respectively.The core area is low lying and is roughly 6 meters above sea level (Figure 1).

Study Population.
The study included all street food vendors in the Takoradi Submetro of the STMA who consented to participate in the study.The included street food vendors were people who directly served already cooked food to customers and the owners of the businesses, aged 18 years and above.However, street food vendors who dissented to partake in the study, helpers, and assistants of food venders were excluded from the study.
2.4.Sample Size Determination.The sample size was determined using the Cochran (1977) formula, n = Z2 P 1 − P / d2, and was estimated based on the proportion of good food safety, and hygiene practice (p) was 62.9% (0.629) from a previous study conducted among Ghanaian street food vendors [1].Parameters in the formula include the following: n which is the sample size, z which is the Z-score (1.96 at 95% confidence interval), P which is the proportion (0.629), and d which is the precision or margin of error (0.05).
Hence, sample size is as follows: where n =0.8966/0.0025and n =358.6,approximately 359.In order to adjust for an anticipated 5% nonresponse rate and also improve statistical power, a total of 408 participants were recruited.

Inclusion and Exclusion
Criteria.All food vendors aged 18 years and above who consented to participate were included; however, food vendors below 18 years and those who did not consent to participate were excluded.[021] 22-23).Prior to data collection, further permission was obtained from the Takoradi Submetropolis of the Sekondi-Takoradi Metropolitan Assembly before the study was started.Written informed consent was obtained from all participants who took part in the study.Likewise, confidentiality and maintenance of anonymity were ensured by using pseudo names.

Data Collection Instrument.
A well-structured questionnaire was used to gather sociodemographic and self-reported food safety and hygiene, knowledge, attitude, and practice (KAP) data from study participants.The questionnaire was a close-ended questionnaire.The statements on KAP were adapted from the WHO's Five Keys to Safer Food guidebook for food handlers.The questionnaire was reviewed and validated by professionals.It was pretested among street food vendors who were excluded from the main data collection.The questionnaire was arranged into four sections, sections A, B, C, and D, and each section contained pertinent information.
Section A sought information on respondents' sociodemographic characteristics such as age, religion, sex, and ethnicity.Section B assessed questions on street food vendors' knowledge of food safety and hygiene.It had 12 items (true/false) regarding awareness of food safety, foodborne disease transmission, knowledge of personal hygiene, knowledge of cross-contamination, and knowledge of temperature control.Section C explored questions on the attitude of street food vendors towards food safety and hygiene.It assessed psychological state concerning views, opinion, moral, and characters to act in particular.It contained 10 attitudinal questions with a 3-point Likert scale (2 = agree, 1 = disagree, and 0 = do not know).Section D contained questions on practices of street food vendors towards food safety and hygiene.It had 9 practice items (yes/no).1).

Knowledge on Food Safety and Hygiene among Food
Vendors.Table 2 presents knowledge on food safety and hygiene among the street food vendors.The majority (69.7%) reported having heard of food safety and hygiene.Most (86.2%) of them indicated that foodborne illness was caused by food contaminated with microbes.About 96% said that it was safe to wash hands for 1 min, with 99.5% indicating that it was safe to wash ingredient properly.Majority (97.5%) of the food vendors also said that it was hygienic not to touch hair, nose, and mouth while serving food to customers.With an estimated mean score of 7.72 (±1.34) for respondents' knowledge on food safety and hygiene, majority (70.4%) of the respondents had low knowledge on food safety and hygiene (Figure 2).

Attitude towards
Food Safety and Hygiene.The majority (99.7%) of the food vendors agreed that regular hand cleaning was needful, with 87% of them concurring that cleaning kitchen shelves lessened the danger of infection.Most (93.8%) of the food vendors agreed that they differentiated healthy diets and rotten food.The majority (99%) of the food vendors agreed that it was vital to dispose meals that have gotten to expiring date.The majority (92.4%) of the respondents also agreed that it is important to cough or sneeze inside the elbow if a towel is not available (Table 3).The overall positive attitude was 49.3% (Figure 3).

Food Safety and Hygiene Practices.
Of the 406 participants, majority (94.8%) indicated that regular cleaning of food and vending site was needful.Most (92.4%) of the food vendors indicated that they washed cooking utensils before preparation of meal, with most (92.1%) of food vendors agreeing that they stored uncooked and cooked meals separately.Also, the majority (85.0%) of vendors reported that they do inspect if a cooked meal was ready by eyeing (Table 4).The overall good food safety and hygiene practices were 46.8% (Figure 4).Data presented as frequency and percentages (%).
5 International Journal of Food Science 3.5.Factors Influencing Knowledge on Food Safety and Hygiene.Table 5 presents chi-square test of associations between sociodemographics and knowledge level of food vendors.The study revealed that the associations between sex (ꭕ 2 = 4 52, p = 0 034), educational level (ꭕ 2 = 15 88, p =0.003), and knowledge level of food vendors were statistically significant.
3.6.Factors Influencing Knowledge on Food Venders.Table 6 presents factors influencing knowledge level of food venders on food safety and hygiene.After adjusting for potential confounder in a multivariate binary logistic regression, educational level was the main factor influencing knowledge level of food venders on food safety and hygiene.Food vendors who had attained a senior high school level of education (aOR = 0 37, 95% CI (0.19-0.70), p = 0 002) were 63% less likely to have low knowledge of food safety and hygiene as compared to vendors with no formal education.Food vendors who had attained a junior high school level of education (aOR = 0 52, 95% CI (0.27-0.99), p = 0 047) were 48% less likely to have low knowledge of food safety and hygiene as compared to vendors with no formal education.7 presents factors influencing the attitude of food vendors towards food safety and hygiene.These estimates are presented in two models: crude odds ratio (cOR) and adjusted odds ratio (aOR).Educational level, training on food safety, and knowledge level of food vendors were the main factors influencing the attitude of food vendors towards food safety and hygiene.Food vendors who had attained a senior high school level of education (aOR = 0 37, 95% CI (0.17-0.82), p = 0 014) were 63% less likely to have a negative attitude towards food safety and hygiene as compared to vendors with no formal education.Also, food vendors who had training on food safety and hygiene (aOR = 0 50, 95% CI (0.29-0.84), p = 0 010) were 50% less likely to have a negative attitude of food vendors towards food safety and hygiene as compared to vendors who had no training.Food vendors with a high level of knowledge (aOR = 0 33, 95% CI (0.20-0.54), p = 0 001) were 67% less likely to have a negative attitude

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International Journal of Food Science towards food safety and hygiene as compared to vendors with a low level of knowledge.

Factors Influencing Practice of Food Safety and Hygiene
among Food Vendors.Table 8 presents factors influencing the practice of food safety and hygiene among food vendors.These estimates are presented in two models: crude odds ratio (cOR) and adjusted odds ratio (aOR).Educational level, family size, knowledge level of food vendors, and their attitudes were the main factors influencing the practice of food safety and hygiene among food vendors.Food vendors who had attained junior high school level of education (aOR = 6 20, 95% CI (2.78-13.87),p = 0 001) were 6 times more likely to have good practice of food safety and hygiene as compared with those with no formal education.Also, food vendors with a family size of 6-7 (aOR = 4 37, 95% CI (2.02-9.43),p = 0 001) were 4 times more likely to have good practices of food safety and hygiene as compared with those with a family size of 1-3.Food vendors with a high level of knowledge (aOR = 4 70, 95% CI (2.77-7.98),p = 0 001) were 4 times more likely to practice good food safety and hygiene measures as compared to those with a low level of knowledge.Food vendors who had a positive attitude towards food safety and hygiene (aOR = 1 76, 95% CI (1.08-2.87),p = 0 023) were 2 times more likely to have good practices of food safety and hygiene as compared with those with a negative attitude.

Discussion
We examined the knowledge, attitudes, and practice regarding food safety and hygiene among street food vendors in the Sekondi-Takoradi Metropolis of Ghana.Our findings showed that the level of knowledge was low among 70.4% of the food vendors and 51% had negative attitudes towards food safety and hygiene.Food hygiene practices were also poor among 52.3% of the participants.Level of education and sex significantly influenced knowledge on food safety and hygiene.Level of education, receipt of training on food safety and hygiene, and level of knowledge were the factors influencing attitude towards food safety and hygiene.Moreover, level of education, family size, level of knowledge, and attitude towards food safety and hygiene were the predictors of food hygiene practices among the street food vendors.
Comparatively, a study in Egypt among 994 food vendors found that only 39.2% of the participants had good food safety knowledge [14].A similar study in Malaysia on the assessment of the knowledge, attitudes, and practices in food safety among food handlers engaged in food courts found that 58.3% of them had poor knowledge [15].On the contrary, a recent study in Ghana by Tuglo et al. [1] reported that 67.3% of the food vendors had good knowledge [1], which is higher compared to the proportion of knowledge observed in the present study.This indicates that knowledge regarding food safety has reduced drastically and calls for immediate action.Another study by Rahman et al. [16] among street vendors in Kuching City revealed that the respondents had good knowledge (41.6%), positive attitude (19.1%), and good practice (10.8%) [16] which is inconsistent with our findings.The differences observed between the studies could be due to variations in sample size and geographical distribution.
The present study found education as the independent predictor of knowledge among food vendors, which contradicts earlier findings by Odonkor et al. [17], which stated that those who had attained primary education had better food safety and hygiene practices compared to the other levels of education [17].Other studies have shown that the odds of having good knowledge were lower among food vendors who had not attained any formal education or had had a primary education compared to those with higher 7 International Journal of Food Science educational status [18].This highlights the fact that food vendors should be encouraged to attain at least a basic education.A study in Indonesia by Cempaka et al. reported a significant association between level of education and the participation in food hygiene training on the KAP level [19].That same study demonstrated that food handlers with excellent knowledge levels were 3 times more likely to have excellent food hygiene practices [19].Moreover, a study in Egypt among 994 food handlers found that higher education was a strong predictor of good food safety knowledge [20], which concurs with our findings.Education increases one's chance to get better information regarding food safety in comparison to those who are noneducated.Also, individuals who are educated can read texts on food safety from leaflets, posters, etc., which may improve their knowledge of food safety.A low level of educa-tion reduces awareness; however, the higher one gets educated the better the knowledge, which affects their attitude and eventually may reflect into good hygiene practices.
Our study also revealed that vendors who had training on food safety and hygiene were significantly associated with lower chances of having negative attitude towards food safety and hygiene.Similarly, a Malaysian study reported that prior training and knowledge were significantly associated with attitude towards food safety and hygiene practices [16].Furthermore, similar studies have reported a significant association between training, knowledge, attitude, and food safety and hygiene practice [15,21].
This association reveals that food handlers with good knowledge have good attitudes and good practices.Thus, actions geared towards the improvement in the knowledge  8 International Journal of Food Science of food vendors will enhance their food safety and hygienic practices.Collaborations of municipal assemblies with other agencies are strongly encouraged to strengthen, sustain, and organize regular training programs for new entrants and existing food vendors as well as retraining of trainers to equip them adequately with knowledge and skills to enable them to effectively facilitate training programs for food vendors.One major limitation of this study was its relatively small sample size; however, it was good enough to draw meaningful conclusions.

Conclusions
Knowledge, attitude, and practices regarding food safety and hygiene were poor among street food vendors at the Sekondi-Takoradi Metropolitan area of Ghana.Our findings suggest that future initiatives should focus on establishing training programs for food vendors within the metropolitan assembly to improve their knowledge on food safety and hygienic practices.

2. 9 .
Data Handling and Statistical Analysis.The data collected were cleaned, coded, and entered into Epi Info version

Figure 2 :
Figure 2: Distribution of knowledge level among study participants.

Figure 4 :Figure 3 :
Figure 4: Bar graph depicting food safety and hygiene practice among street food vendors (N = 406).

Table 1 :
Sociodemographic characteristics of respondents.Ethical Considerations.Ethical clearance was obtained from The Ghana Institute of Management and Public Administration (GIMPA-REC.

Table 2 :
Knowledge of food safety and hygiene among street food vendors.
3.1.SociodemographicCharacteristics of Food Venders.Table1presents the sociodemographic characteristics of the respondents.The mean age of the 406 food vendors was 38.23 (±7.74), with majority (57.1%) of the food vendors aged below 40 years.Majority (90.2%) of the food vendors were females and were married (63.6%).Seventy-nine percent was Christians, with no prior formal training on food vending (63.2%) (Table

Table 3 :
Attitude towards food safety and hygiene among food vendors.

Table 4 :
Food safety and hygiene practices among food vendors (N = 406).
Data presented as frequency and percentages (%).

Table 5 :
Bivariable analysis of factors influencing knowledge on food safety and hygiene.

Table 6 :
Multivariable analysis of factors affecting the knowledge level of food vendors.: reference; cOR: crude odds ratio; aOR: adjusted odds ratio.p < 0 05 was considered statistically significant, and bolded p values are significant. Ref

Table 7 :
Multivariable analysis of factors affecting the attitude of food vendors.
Ref: reference; cOR: crude odds ratio; aOR: adjusted odds ratio.p < 0 05 was considered statistically significant, and bolded p values are significant.

Table 8 :
Multivariable analysis of factors affecting food safety and hygiene practices among food vendors.Variable Practice (n = 406) ꭕ 2 (p value)/Fisher's exact cOR (95% CI) p value aOR (95% CI) p value Bad (n = 216) Good (n = 190) cOR: crude odds ratio; aOR: adjusted odds ratio.p < 0 05 was considered statistically significant, and bolded p values are significant.9 International Journal of Food Science