Cite

Introduction

Up until 2018, the Serbian system of food control was at an unenviable level, and thus there was a lot of space for numerous failures, often with very serious consequences for people’s health (1). However, as of 1 January 2018, the use of a new integrated system of management and control of food safety, developed with EU support, was implemented.

In Serbia, as well as in other countries round the world, foodborne illnesses or food poisoning are becoming a major health problem of primary importance (2). The diseases caused by food poisoning, both in developing countries such as Serbia and in the developed countries of Europe and the USA, can cause significant morbidity and mortality from foodborne illnesses (3).

Meta analysis (4) highlights the heterogeneity between food groups, and the fact that many factors influence consumers’ product preferences and purchasing decisions, and this can also be considered a health problem. There are numerous studies emphasizing that food handlers of all ages consider that they know how to handle food safely, but their self-reported food handling behaviors do not support this supposition (5, 6, 7, 8). Food mishandling is more common in some consumer groups than in others (9, 10). Young male adults (18-29 years old), men, and individuals with education higher than high school are more likely to have risky food handling than others (11, 12, 13). This age group (18-29 years old) is not considered to be “at risk” for foodborne illness. However, the consequences of their unhygienic food practices become serious when they start providing care for other household members who are at risk, such as pregnant women, young children, and ageing adults (14, 15).

Accordingly, relevant research has been done to date in Greece (16), Slovenia (17), Bulgaria (18), Spain (19), Sweden (20), Turkey (10, 21, 22), Jordan (23), Lebanon (24), Saudi Arabia (25, 26), Malaysia (27, 28, 29), Canada (30), Australia, and the UK (31). The reports from the listed countries indicated a significant level of awareness of food safety knowledge among a similar profile of respondents but with a constant need for new educational initiatives. This should involve the promotion of more optimal behaviors, improvement in food safety practices, and interventions on food safety. The majority of the research showed that a university environment is an ideal place for implementing the strategy of prevention of the diseases caused by improper food handling, since they will be the ones who will cook, train, and be parents in the future.

It is interesting to point out that a related study had already been done among the cadets of the Military Academy in Serbia (32). The evaluation of the level of food safety knowledge among them showed relatively good knowledge of some food safety issues, including prevention of cross contamination in the kitchen, hand and personal hygiene. Another similar research (33) evaluated self-reported food handling practices and food safety knowledge among undergraduate students in Serbia, with the aim of determining whether the university curriculum influences the food safety outcome among participating students.

Considering previous studies, this research will focus on the assessment of knowledge about food safety and self-reported food handling practices among students of the three public universities in Serbia – University of Belgrade, University of Niš, and University of Novi Sad. The analyzed universities are the largest academic and scientific institutions in Serbia in terms of the number of students, departments, faculties, and staff.

Methods
Study population

The study was conducted from October to December 2020. An email requesting students’ participation and containing the link to the survey was sent to 1,000 students in Novi Sad, Belgrade, and Niš by the University’s Registrar’s Office. The population was from different fields of study (health-related and non-health-related) and years of study (second, third and fourth years). Out of 1,000 filled questionnaire forms, 930 (79.5%) were filled correctly (respondents answered all questions) and were used for further statistical analysis.

Table 1 presents a sample design which includes information about the sample and population, sampling error, and confidence level.

Sample design research data.

Collection method Self-administrated questionnaire

Sampling unit Students over 18 years of age
City Novi Sad Belgrade Niš
Sampling error 3.8% 5% 3.2%
Confidence level 95% 99% 95%

Sampling unit 140,500 per year
Questionnaire

The questionnaire was developed by incorporating questions selected from an updated, reliable, and valid instrument produced by Byrd-Bredbenner et al. (9), and used in similar studies done in Serbia (32, 33). Appropriate modifications were made to some of the selected questions, as regards adjustments to specific eating habits in Serbia. The questionnaire was subjected to a preliminary validation (81 students, 27 per city) to assess its clarity, the suitability of wording, and the average time needed for its completion. Based on this pilot study, necessary modifications were identified and resolved, but its results were not included in the final survey.

The final questionnaire consisted of four parts: introduction, demographic characteristics, self-reported food handling practices, and food safety knowledge questions. The demographic characteristics included gender, age, field of study and year of study, campus, residential area and status, involvement in cooking, and parental employment. The self-reported food handling practices section included 16 questions, while the food safety knowledge section included 14 questions. Most of the items were multiple-choice questions.

Statistical analysis

IBM SPSS Statistics v18 software was used for all the statistical analyses. The demographic characteristics represented the independent variables. Food-safety and handling knowledge and practices outcomes represented the dependent variables. Each multiple-choice item had one correct answer that was assigned a score of 1 point, while 0 points were assigned to all the wrong answers. A T-test and Analysis of Variance (ANOVA) were conducted to compare the mean sum of the correct responses of every section of the questionnaire.

Results

A total of 930 undergraduate students participated in the study: 54% females and 46% males. The study sample was composed 30% of students from health-related fields of study (nutrition, biology, chemistry, medicine, and pharmacy) and 69% from non-health-related fields of study (arts, engineering, law, and business) (Table 2). The mean student age was 21 (SD=1.7). Four percent of them were first years, 41% were second years, 29% were third years, and 25% were fourth years. Around 68% of the students lived with their parents. Only 6% of the students reported that they cook their own meals daily. Of all the students, 30% of them had a working mother.

Demographic characteristics of the study population (N=930).

Demographic variables %a
Gender Male 45.1
Female 54.9
Age group 18-20 67.9
21-23 33.1
Field of study Health-related 30.8
Non-health-related 69.2
Year of study First 4
Second 41.1
Third 29.8
Fourth 25.1
Campus Novi Sad 32.4
Belgrade 43.5
Niš 24.1
Residential area City 51.2
Suburb 38.5
Rural area 10.3
Cooking habits Cook daily 9.6
Sometimes 33.4
Rarely 30.7
Maternal employment Never 26.0
Works 30.7
Housewife 69.3

relative percentage based on valid values

The overall food handling practices score was the sum of the correct responses in the self-reported food handling practices section for each student, and its mean value was 45.7% (SD=15.7). The mean score and the significance levels for each variable are presented in Table 3. In terms of food handling, female students scored significantly (p<0.001) better than male students. Also, students in health-related fields scored significantly (p<0.001) better than non-health-related ones. In addition, the residence area had a significant (p=0.006) effect with City scoring the highest, and Rural area the lowest. Moreover, students having working mothers scored better than those whose mothers are housewives, and the significance was borderline significant (p=0.05). On the other hand, age, year of study, campus, residential status, and cooking habits were not significantly associated with practice and knowledge scores (p>0.05).

Mean scores for self-reported food handling practices and food safety knowledge sections per demographic characteristics.

Demographic variables Self-reported food handling practices
Food safety knowledge
Mean±SDa Sig.* Mean±SDa Sig.*
Age 18 44.7±13.2 0.370 0.127
19 44.8±14.4
20 43.2±14.4
21 42.8±13.6
22 43.5±15.1
23 44.4±15.0
Gender Male 43.4±13.8 0.001 0.113
Female 47.4±14.3
Field of study Health-related 48.8±13.3 0.001 0.001
Non-health-related 42.9±13.8
Year of study First 42.3±13.7 0.635 0.07
Second 44.3±13.9
Third 45.8±14.7
Fourth 48.4±14.1
Campus Novi Sad 45.8±15.1 0.251 0.316
Belgrade 44.5±13.8
Niš 44.1±12.9
Residence area City/Town 55.8±15.1 0.006 0.112
Suburban area 51.3±14.3
Rural area 32.5±19.1
Residential status Parents 48.6±12.7 0.909 0.009
Friends/roommates 44.9±15.1
Alone 46.1±14.3
Cooking habits Daily 48.1±15.7 0.605 0.001
Sometimes 45.3±15.1
Rarely 43.9±13.8
Never 43.1±14.1
Maternal employment Works 48.1±15.1 0.05 0.09
Housewife 45.1±14.8

Note: a knowledge score, relative percentage based on valid values; *statistical significance p<0.05

The mean food-safety knowledge score was 57.9% (SD=15.1). The mean score and the significance levels for each variable are presented in Table 3. There was no statistically significant difference (p=0.106) between female and male students. Students in health-related fields scored significantly (p=0.001) better than non-health-related ones. The higher the year of study, the higher the knowledge score was. Senior students scored the highest, followed by third years, second years and first years, and the difference was border-line significant (p=0.07). Students living with parents scored significantly (p=0.09) higher than those living alone or with friends. Students who cook daily scored significantly (p=0.001) lower than those who cook less frequently or never.

Students from health-related fields of study reported the highest average self-reported food handling practices (48.8%) and food safety knowledge (57.7%) scores (Table 3). The difference between these students and their counterparts from non-health-related fields of study was significant (p<0.05) for both self-reported food handling practices and food safety knowledge parts. This could be due to the presence of modules and courses relevant to food safety, hygiene and microbiology in the curricula of health-related fields of study.

Fourth-year students reported higher food safety knowledge scores (57.2%), followed by third-year (53.8%), second-year (51.9%) and first-year (49.9%) students, and the difference was border-line significant (p=0.07) (Table 2). This can be attributed to the fact that as the students, especially in health-related fields of study, stay longer in the field of study, they cover more aspects of food safety (16, 24). Male and female students were equally (~54%) knowledgeable in terms of food safety (Table 3); however, female participants responded significantly (p<0.001) better (46%) than males (42%) in terms of self-reported food handling practices. This conforms to the findings from previous studies, in which females outperformed male university students (9, 16, 24).

Students from the campus of Novi Sad had the highest score (45.8%) for the questions regarding self-reported food handling practices, followed by those from Belgrade (44.5%), and Niš (44.1%), whereas for the food safety questions, the highest score was reported for the students from the campus in Belgrade (54.5%), followed by Novi Sad (53.3%), and Niš (52.9%). No statistical significance has been found (Table 3).

Students living with their parents scored better (Table 3) than those living alone or with friends or roommates; however, the difference was only significant (p=0.009) for the food safety knowledge questions. This can be attributed to the fact that when students live with their parents, someone else who is more experienced (most often, the mother) will handle the food preparation, resulting in better food handling and an opportunity for students to observe and learn more about food safety.

Detailed scores on the self-reported food handling practices and food safety knowledge questions are presented in Tables 4 and 5. In the self-reported food handling practices section, the highest score was for hand washing; 89% of the participants reported that they wash their hands with soap and water before eating or preparing food. On the other hand, the lowest score was for how to check that a burger is cooked enough; only 8.7% of the participants reported that they use a thermometer to check the temperature at the center.

Score distribution for questions related to self-reported food handling practices.

Questions Multiple-choice responses Correct responses
Novi Sad Belgrade Niš
(1) At home, what is most practiced after Use the board as it is 1.8% 3.3% 3.4%
using a cutting board to slice raw meat Wipe the board with a paper towel 1.9% 3.4% 3.6%
and need to cut tomatoes afterwards? Wash the board with soap and water 36.1% 45.9% 40.4%
Use a different cutting board 60.9% 54.1% 50.5%
(2) On campus, how do you dry Paper towel 87.1% 87.8% 85.6%
your hands after washing them? Hot air electrical dryer 5.9% 5.2% 6.9%
Leave them to dry on their own 2.9% 2.3% 3.4%
Your clothes 2.1% 2.7% 2.1%
(3) In the fridge (not freezer) of your Top shelf 57.4% 56.1% 56.9%
house, where is the raw meat stored? Medium shelf 8.4% 5.8% 6.7%
Lowest shelf 30.2% 34.2% 31.7%
(4) If you have a sore on the back of Yes, but after putting a bandage on it 33.6% 34.9% 35.1%
your hand, do you prepare food? Yes, but after putting on a glove 12.1% 15.6% 15.6%
Yes, but after bandaging the sore and putting on a glove 29.4% 28.1% 27.9%
No, I do not prepare food until the sore heals 23.1% 19.4% 17.6%
(5) When you cut raw meat and need to Reuse the knife as it is 1.4% 2.2% 3.2%
use the knife again, what do you do? Rinse the knife with cold water 17.5% 15.0% 16.1%
Wash the knife with soap and water 76.1% 78.1% 77.3%
Wipe the knife with a cloth 3.2% 2.9% 1.9%
(6) Do you take off jewelry Yes 79.3% 76.8% 75%
when preparing food? No 19.1% 21.5% 23.4%
Not applicable 1.4% 1.3% 1.1%
(7) At home, how do you check By checking the color 40.1% 35.9% 39.3%
that a burger is cooked enough? By checking the firmness 36.1% 40.0% 38.4%
By measuring the temperature at the center 8.7% 8.1% 8%
By checking the cooking time 12.1% 11.5% 11.1%
(8) At home, you fry eggs until the: Egg white is solid and the yolk is semi-solid 24.2% 22.8% 23.9%
Egg white and yolk are semi-solid 7.3% 6.7% 8.8%
Egg white and yolk are solid 56.2% 58.3% 57.7%
(9) During your supermarket At the beginning of shopping 7.2% 9.6% 10.2%
shopping, when do you place About halfway through the shopping 8.4% 10.2% 11.9%
refrigerated meat in your cart? At the end of the shopping 59.7% 57.5% 54.2%
It does not matter 22.8% 20.6% 22.8%
(10) At home, how do you defrost Heat it in a microwave 17.2% 12.7% 18.9%
frozen meat/chicken? Put it under running water for 1 h 14.3% 19.7% 18.1%
Leave it on the kitchen counter for 1h 38.5% 31.2% 33.1%
Leave it in the fridge for a few hours 28.8% 26.5% 27.1%
(11) Do you have a thermometer Yes 55.2% 53.7% 54.6%
in your fridge? No 43.7% 44.2% 44.3%
(12) If your roommate or family member In the fridge 30.1% 27.3% 38.5%
is going to be several hours late for a hot In a cool oven 24.2% 22.5% 23.1%
meal, where do you leave the meal? In a warm oven 32.3% 37.8% 39.7%
On the counter 13.0% 12.5% 9.6%
(13) When preparing food, you wash your Your face 36.9% 33.4% 32%
hands after touching which of these? Clean pots and counter 9.1% 8.6% 7.1%
Utensils being used in food preparation 33.7% 31.2% 31.7%
I do not wash my hands after touching any of the above 15.7% 15.2% 14.8%
(14) At home, how do you treat Dip them in water and salt 5.8% 5.9% 5.7%
fresh fruit and vegetables? Wash them with soap 16.7% 16.9% 16.6%
Wash them under running water 71.4% 70.9% 71.1%
Boil them 3.5% 3.7% 3.8%
(15) How often is the kitchen sink Daily 52.1% 48.6% 46.7%
drain in your home sanitized? Weekly 23.9% 24.4% 22.1%
Never 2.9% 2.4% 3.9%
Only when I wash food in the sink 10.1% 12.6% 13.8%
(16) How do you wash your hands Soap and water 97.1% 97% 96.9%
before cooking or eating? Water only 1.5% 1.4% 1.3%
Hand sanitizer 0.9% 1.1% 1.2%
I do not wash my hands 0.3% 0.2% 0.2%

Note: The best practices are highlighted in bold.

Score distribution for questions related to food safety knowledge.

Questions Multiple-choice responses Correct responses
Novi Sad Belgrade Niš
(17) Which of the following scenarios for Soap, then water, then sanitizer 82.7% 81.3% 80.1%
cleaning kitchen counters is the BEST? Sanitizer, then water 8.2% 8.2% 8.7%
Brush, then sanitizer 4.9% 5.9% 5.7%
Water, then drying 2.5% 2.9% 1.8%
(18) While washing your hands, it 10 seconds 24.1% 23% 23.1%
is enough to rub them for…? 20 seconds 32.7% 33.4% 30.7%
30 seconds 27.4% 28.7% 25.9%
40 seconds 5.2% 4.3% 4.7%
(19) Freezing kills harmful germs in food. True 31.0% 29.3% 30.2%
False 67.8% 69.1% 67.2%
(20) Which food is the LEAST Baked potato left on the kitchen counter overnight 27.8% 27.3% 26.1%
likely to cause food poisoning? Leftover chicken eaten cold 16.3% 15.8% 16.1%
Chocolate cake left on the kitchen counter overnight 37.1% 38.6% 36.9%
Slices of pizza left on the counter overnight 17.1% 16.6% 18.8%
(21) What is the recommended -18°C 72.5% 73.4% 72.1%
temperature for freezers? 18°C 4.2% 3.9% 4.1%
8°C 5.9% 5.6% 5.7%
0°C 14.2% 13.9% 14%
(22) What is the recommended -4°C 11.3% 10.3% 9.9%
temperature for fridges? 4°C 68.2% 67.9% 67.8%
12°C 10.1% 11.1% 10.7%
16°C 6.6% 6.3% 6%
(23) Which food does NOT Fruit salad 4.8% 4.5% 4.3%
need to be refrigerated? Open can of peas 6.9% 6.4% 6.1%
Raisins 82.2% 80.2% 79.9%
Chocolate pudding 6.1% 5.5% 5.7%
(24) How can food be made safe if Cook it well 65.9% 66% 65.7%
it has salmonella bacteria in it? Freeze it for 3 days 7.3% 7% 7.1%
Such food cannot be made safe 5.2% 4.9% 5%
Don’t know 19.3% 19.6% 19.9%
(25) For a burger to be safe to 52°C 12.4% 11.4% 12.9%
eat, it needs to be cooked until its 71°C 33.1% 33.6% 32.9%
internal temperature reaches: 121°C 27.3% 28.7% 29.3%
130°C 10.4% 9.4% 8.4%
(26) The microorganisms that cause Bacteria 62.8% 63.5% 62.1%
most foodborne illnesses are: Viruses 9.9% 10.9% 9.1%
Parasites 8.4% 8.9% 8%
Fungi 14% 13.8% 15.1%
(27) Which of these individuals should A person with diarrhea 10.1% 9.9% 9.7%
NOT prepare food for other people? A person with severe acne 19.7% 22.1% 20.1%
A person with HIV 14.5% 13.1% 17.1%
A person with a cold 51.8% 49.8% 46.3%
(28) Which food do pregnant women, Soft cheeses 38.4% 39.9% 36.1%
infants, and children need NOT to avoid? Raw or undercooked eggs 14.1% 13.7% 11.3%
Undercooked hot dogs 2.6% 1.3% 4.6%
Canned vegetables 41.3% 42.9% 44.1%
(29) Which of these individuals are the Old people 13.1% 16.1% 15.1%
LEAST likely to get food poisoning? Pregnant women 8.3% 14.9% 10.6%
Teenagers 63.7% 60.7% 59.9%
Cancer patients 14.9% 8.3% 12.1%
(30) Most disease-causing bacteria can 5-60°C 30.7% 31.3% 29.9%
grow within a temperature range between: 20-40°C 39.1% 40.3% 37.9%
40-60°C 13.9% 8.9% 16.3%
30-70°C 8.8% 10.8% 7.9%

Note: The correct answers for the knowledge questions are highlighted in bold.

From the detailed insight into the scores for responses to the 16 questions related to self-reported food handling practices, it can be concluded that the students from Novi Sad had the highest score, for as many as 10 questions, followed by the students from Belgrade, and then Niš. At the same time, the students from Novi Sad showed the best knowledge about the use of a thermometer for checking the temperature at the center of the item.

The distribution of the results, for the questions regarding food safety knowledge, is shown in Table 5. In the field of food safety, the students had the highest scores (82.7%) for the best way of cleaning the kitchen counter. However, only 10.1% knew that a person with diarrhea should not prepare food for others.

Discussion

In the last 15 years, a range of research (10, 16, 17, 18, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33) has been conducted in order to assess the knowledge, attitudes, and practices related to food safety among students, and at universities, and they have all had a similar contribution, which can be seen in the continuity of the conducted studies and the results of this research. The study proved that students from the University of Novi Sad had better knowledge related to self-reported food handling practices, whereas students from Belgrade had better knowledge regarding food safety basics. In the previous study (33), students from both universities had the same score for self-reported food handling practices, but students from the University of Novi Sad had a better knowledge than students from Belgrade regarding food safety basics. In our study, the overall food handling practice score was the sum of the correct responses in the self-reported food handling practices section for each student and its mean value was 45.7% (SD=15.7), while the mean score for the food-safety knowledge was 57.9% (SD=15.1). A similar finding was reported in Lebanon (24), Greece (16), and Serbia (32, 33). Lazou et al. (16) reported that the mean scores of food safety knowledge and self-reported food handling practices among Greek university students were 60% and 44% (16), in Lebanon they were 53% and 44% (24), and in Serbia they were 56% and 46% (32, 33).

In terms of self-reported food handling, female students scored significantly (p<0.001) better than male students. On the other hand, there was no statistically significant difference between female and male students regarding food-safety knowledge. Similar results have been determined for female students in Lebanon (24) and Serbia (33), and the opposite was seen for students of Veterinary Medicine in Bulgaria (18).

Regarding the results of fields of study, students from health-related fields of study reported the highest average self-reported food handling practices and food safety knowledge compared with students of non-health-related fields of study. A similar finding was reported in Lebanon (24), Greece (16), and Serbia (33).

Study limitations and recommendations for future research

One of the limitations of the research is the methodological difference relative to previous studies. Despite the differences, all the studies so far have concluded that the results are similar regarding food safety and self-reported food handling practices among students. Nevertheless, the sample size should be increased in the future. This would include respondents from other public and private universities in Serbia and neighboring countries. As a result, the complete picture of the study would have a bigger sample size and outcomes would be even more important, comparable, and interesting to analyze.

It is of note that this study was performed before the onset of the COVID-19 outbreak, which is currently ongoing at the time of writing this paper. Future research should analyze if the hand hygiene knowledge and handling practices among students and among other groups of food handlers was significantly improved, due to numerous instructions, guidelines and videos that have been presented during this pandemic (34, 35). Despite the limitations of this study, which require further research, we can draw certain conclusions from the findings summarized in the next chapter.

Conclusion

This research was conducted in Serbia and examined students from the largest national public universities in Novi Sad, Belgrade, and Niš, regarding food safety and self-reported food handling practices. On the one hand, as currently observed, a high level of students’ awareness of food safety contributes to the higher consumption of food, but it also represents a risk that can be caused by food handling, and thus a greater proneness to food poisoning. On the other hand, if observed long-term, this is an advantage, since the target group will act as parents in the future, and they will prepare food and meals. The research results point to the fact that there is a strong correlation between the participants’ demographic characteristics and self-reported food handling practices, as well as food-safety knowledge, which is in accordance with the results of previous studies. The contribution of the research reflects a great need for education on food safety for young people. A university environment is an ideal place for this, and the students are the target group where it is possible to apply the strategy of preventing diseases caused by incorrect food handling, as well as education on food safety and food handling practices.

eISSN:
1854-2476
Language:
English
Publication timeframe:
4 times per year
Journal Subjects:
Medicine, Clinical Medicine, Hygiene and Environmental Medicine