1 Introduction

Food safety is a collection of vital concepts used to attain the best environmental situations through handling, storing, processing, preparing, and serving food [1]. Ensuring food safety is fundamental for all people at all levels as it is critical for developing a productive citizen that enhances swift economic, social, and sustainable growth [2]. However, the issue of food safety remains a critical problem in low and middle-income countries, including Ethiopia [3, 4]. Foodborne diseases endanger global public health security and stay a pressing global public health challenge [5]. According to the World Health Organization data, an estimated 600 million (nearly 1 in 10 people) infections and 420,000 deaths are due to using contaminated food [6].

Furthermore, eating unsafe food causes an estimated 33 million years of healthy lives to be lost annually [6, 7]. Even in the United States of America, an estimated 48 million cases of foodborne illness happen each year, resulting in about 128,000 hospitalizations and 3000 deaths [8]. Of the 9040 food-associated outbreaks reported to the Center for Disease Prevention and Control from 1998 to 2004, 52% were attributed to restaurants, cafeterias, and hotels [9]. Moreover, 66% of foodborne disease outbreaks reported in 2006 and 2007 were attributed to food establishments or restaurants [8]. In particular, the effects of foodborne diseases resulting from weak food safety practices are estimated to be more severe in low and middle-income countries, including Ethiopia [10, 11]. Poor regulatory systems, inadequate food safety laws, insufficient hygiene, cleanliness, and poor environmental health conditions are the major factors of poor food safety practices in food establishments [12]. In addition, using unclean water for washing utensils, cleaning, and preparing food can be a critical factor for poor food safety practices resulting in a high prevalence of foodborne diseases. Foodborne diseases associated with poor food safety practices are typically infectious and caused by bacteria, viruses, and parasites entering the body through contaminated food [13]. Many studies revealed that microbiological contamination of food occurs in food outlets. The contamination could be due to negligence of food handlers, cross-contamination, poor access to potable water, dirty food contact surfaces, and other unknown factors [14, 15].

Despite the lifestyle of the current generation changing and urbanization directing people to eat away from home-based frequently, most food outlets that provide the services are suspected of having poor food safety practices. Food consumed at food establishments has been identified as an important source of foodborne disease outbreaks and creating a tremendous public health problem [16]. Further, the poor water quality of food outlets causes many waterborne diseases to customers, exposing them to serious health problems and financial losses [17]. The first things that come to mind when considering food safety are handwashing stations, time, temperature, and cross-contamination [18]. However, every food outlet depends on clean water for its basic functions [19]. Without clean water, food outlets have no food safety [20]. Many studies showed that food-related health problems are directly or indirectly associated with water [21, 22]. Failure to ensure drinking water quality may expose food outlet customers and the community to the risk of outbreaks of many infectious diseases [23, 24]. As a result, the importance of clean water to human health and well-being is encapsulated in the Human Right to Water and Sanitation, which states that “everyone has the right to obtain clean, sufficient and affordable water for personal and domestic uses” reaffirmed by the United Nations General Assembly and Human Rights Council [25]. Ethiopia has similarly emphasized the importance of Sustainable Development Goal 6 by establishing national drinking water standards to enhance public health. However, only 42% of Ethiopians have access to a clean water supply [26]. To ensure optimal practices in food safety, food outlets must have access to high-quality water [27]. However, a significant health problem is associated with poor food safety practices resulting from poor water quality [28]. Therefore, this study aimed to identify factors associated with food safety practices and drinking water quality of food outlets in Bishoftu Town, Ethiopia.

2 Methods

2.1 Study area

Bishoftu town is located in Oromia National Regional State at a distance of 44 km from the capital city of Addis Ababa. The area of the Town is estimated to be 18,278 hectares [29]. The Town is divided into nine urban Kebeles and five rural Kebeles. Besides, the Town has an estimated 171 227 population [29]. According to the Bishoftu Town health bureau data, the Town has an estimated 366 food establishments.

2.2 Study design and period

An institutional-based cross-sectional study was conducted among food establishments in Bishftu Town from January to February 2022.

2.3 Source population

The source population for this investigation was all food outlets located within Bishoftu Town city administration.

2.4 Study population

All selected food establishments located in Bishoftu Town administration were the study population.

2.5 Sample size determination

The study’s sample size was calculated using a single population proportion formula with 95% CI, 5% marginal error (m), and p = 27.4% proportion of food handlers having good food safety practices from the previous study [30]. Then,

$${\text{n}} = \frac{{\left( {{\text{Z}}^{2} } \right) * {\text{P}}\left( {{1} - {\text{P}}} \right)}}{{{\text{m}}^{2} }}$$
$${\text{n}} = \frac{{\left( {1.96} \right) * \left( {1.96} \right) * \left( {0.274} \right) * \left( {1 - 0.274} \right)}}{0.05 * 0.05} = 305$$

However, since the sampling was from a finite population of size 336 (N < 10,000) total food establishments in Bishoftu Town, the authors used the population correction formula as follows:

$${\text{n}} = \frac{{{\text{no}}}}{{\left( {{1 + }\frac{{{\text{no}}}}{{\text{N}}}} \right)}}$$

where n is the final calculated sample size, no is the calculated sample size, and N is the total number of food establishments in the Town. Then,

$$\begin{aligned} {\text{n}}_{{{\text{final}}}} = & \frac{305}{{1 + \frac{305}{{336}}}} \\ = & 160 \\ \end{aligned}$$

Therefore, the sample size (n) for this study was = 160 food establishments.

2.6 Sampling procedures

The food establishments were selected using a systematic random sampling method. A sampling frame or a listing of the 336 food establishments was obtained from the Bishoftu Town Health bureau. Those food establishments were divided by the sample size of this study (160) to get the sampling interval. Then, two sampling interval was determined. After this, one food establishment was selected using a lottery method and continuous by adding the sampling interval to get the required 160 food establishments. Drinking water samples were taken from the food establishments' drinking-water storage and were bacteriologically and chemically tested. Heat-sterilized bottles of 250 ml capacity for bacteriological and 1000 ml plastic bottles for chemical parameters were used to collect drinking-water samples. The sampling methods were adapted from the WHO guidelines for drinking water quality [31]. The bottles were arrived at the laboratory within 6 h and refrigerated at four-degree celsius until the analysis time.

2.7 Data collection procedure

A structured questionnaire and observational checklist adopted from related studies [32,33,34] were prepared to assess the food safety practice of food establishments. Data were collected by eight trained Bachelor of Science holder health professionals. Sufficient training was given to data collectors to increase data reliability. Managers were interviewed to assess the food safety practices of food outlets. Concurrently, an observational checklist was completed to determine the food safety practices of food establishments. A pre-testing was done on 5% of the total sample size, and questionnaires were checked for completeness and consistency. Questions that lacked clarity were reshaped and modified.

2.8 Study variables

2.8.1 Dependent variables

The response variables of this study were food safety practices and drinking water quality.

2.8.2 Independent variables

The predictor variables of this study were the sex of the food outlet managers, age of the managers, educational level of the managers, marital status of the managers, service-based type of food establishments, service years of food establishments, ownership of the food establishments, having renewed licenses, estimated daily number of customers, trained managers about hygiene and sanitation, and trained food handlers about hygiene and sanitation.

2.9 Operational definitions

Food establishments were evaluated using 28 practice-related checklists to determine the level of food safety practice. Every question had at least two choices. A correct answer for good food safety practice was given a score of 0, whereas a score of 1 was given for poor food safety practice. Then, all individual answers were summed up for total scores and calculated for the percentage mean. Food establishments that scored less than the average value (76%) were assumed to have poor food safety practices, and those that scored greater than or equal to the average value (76%) were supposed to have good food safety practices. In addition, drinking water quality was determined according to the World Health Organization drinking-water guideline [35]. Drinking-water samples with < 1 Colony Forming Unit (CFU)/100 ml for indicator bacteria were assumed as uncontaminated, and samples with ≥ 1 Colony Forming Unit (CFU)/100 ml were contaminated. Besides, drinking water samples with ≤ 1.5 mg/liter and ≤ 50 mg/liter of fluoride and nitrate values were assumed to be free from chemical contamination, respectively. Furthermore, drinking water samples with > 1.5 mg/liter and > 50 mg/liter concentration values of fluoride and nitrate were assumed to be chemical-contaminated, respectively.

2.10 Analysis

Data were checked for accuracy and transferred from Open Data Kit (ODK) into the Stata version16 for analysis. Descriptive, binary, and multivariable logistic regression analyses were conducted. The membrane filtration method was used for microbiological analysis of the drinking water. According to the United States Food and Drug Administration, the enumeration of Escherichia coli, Total Coliform, and Fecal coliform bacteria was performed using the membrane filtration method [36]. Furthermore, according to the United States America Environmental Protection Authority (USEPA) guideline, Ion-Selective Electrode (ISE) was used to determine fluoride levels in drinking water [37]. In addition, nitrate concentration was determined by the Ultraviolet spectrophotometer screening method according to the American Public Health Association/American Water Works Association/Water Environment Federation (1998) Standard methods for examining water and wastewater [38].

2.11 Ethical considerations

Ethical approval was obtained from the Ethiopian Public Health Institute scientific and ethical review board with reference number EPHI-IRB-358-2021. The aim of this study was clearly explained to the food establishment managers, and they reached an agreement. Then, written consent was obtained from the managers, and those who did not wish to take part in the study were not forced to participate. The confidentiality and anonymity of participants were ensured during the survey.

3 Results

3.1 Sociodemographic characteristics of food establishment managers

A total of 160 food outlet managers were included, with a response rate of 93.13%. Of the total participants, 67.8% of the managers were male. The mean age of the managers was 40 years. Forty-six percent of the managers’ educational status was completed secondary school. Regarding marital status, 71.1% of the managers were married. Most (94.6%) of the food establishments had a legal license from the food and drug administration office. In this study, 73.2% & 22.8% of the managers of the food establishments and food handlers were not obtaining training in hygiene and sanitation in the past year, respectively (Table 1).

Table 1 Sociodemographic characteristics of food establishment managers (n = 149)
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3.2 Food safety practices among food establishments

The average score of food safety practice questions of the food establishments was 76%. Yet, based on the cutoff point, only 51% of the food establishments had good food safety practices. A large number (29.5%) of the food establishments were not purchasing food items from approved or reputable suppliers. Also, 33.6% of the food outlets had not a functional refrigerator. A significant number (41.6%) of food outlets did not appropriately place food in a fridge. Almost all (98.7%) food outlets separate cooked and raw foods.

Furthermore, 81.9% of the food outlets shelved food utensils in a dry place. A large number (38.9%) of the food handlers of the food outlets were not using personal protective devices during the survey. Besides, 53% of the food handlers of the food establishments had no medical certificate. Nearly half (47.7%) of the food outlets had no internal sanitary inspection practice. Most importantly, 85.2% of the food outlets had no drinking-water treatment practice. Further, 45% of the food outlet kitchens had no three dishwashing systems (Table 2).

Table 2 Food safety practice among food and drinking establishments (n = 149)
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3.3 Factors associated with food safety practice

Binary logistic regression analysis was conducted to identify determinant factors of food safety practices of the food outlets. In this model, ten predictor variables, including sex of the food establishment managers, age of managers, marital status of managers, type of food establishments, services year of food establishments, ownership status of food establishments, legal license from food and drug administration office, trained managers about sanitation and hygiene, trained food handlers about sanitation and hygiene, and the number of food handlers were significantly associated (P-value < 0.05 at 95%CI with food safety practice of food establishments. Multivariable logistic regression analysis was performed to reduce the effect of confounding factors. In this model, only seven explanatory variables, including sex of the food establishment managers, marital status of managers, type of food establishments, services year of food establishments, ownership status of food establishments, trained food handlers about sanitation and hygiene, and the number of food handlers were significantly associated (P-value < 0.04 at 95%CI with food safety practice of food establishments (Table 3).

Table 3 Multivariable logistic regression analysis
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3.4 Bacteriological and chemical drinking-water quality of food establishments

Most of the drinking water samples from the food outlets, as seen in Fig. 1 below, were free of microbiological and chemical pollutants.

Fig. 1
figure 1

Bacteriological and chemical drinking-water quality of food outlets

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3.5 Sanitation and hygiene facilities of food outlets

Most (91%) of the food outlets had a functioning restroom, while 9% had no. Most (97.3%) of the food establishments used improved sanitation facilities. Many (18.8%) food outlets had no functional hand washing facility near the toilet. Also, 8.7% of the food outlets had no operational handwashing facilities in the kitchen. We found that 22.8% of the food outlets had no septic tanks to manage liquid waste. Most importantly, 84.6% of the food outlet kitchen solid wastes' stayed inside the kitchen, still in final disposal (Table 4).

Table 4 Sanitation and hygiene facilities of food outlets
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4 Discussion

The current study aimed to identify determinant factors of food safety practices and drinking water quality of food establishments. Multivariable logistic regression analysis was conducted to identify the food outlets' predictor variables of food safety practices. Accordingly, many factors influencing the food safety practice of food establishments were identified. Finding the elements that influence food safety practices can help to develop suitable preventive measures that improve the food safety practices of the food outlets.

Food establishments with female managers were 3.7 times higher in good food safety practices than those with male managers (AOR = 3.7, with 95% CI 1.33–10.21). Moreover, food establishments that owned trained food handlers in sanitation and hygiene were 4.8 times more likely to be in good food safety practices than those that did not have trained food handlers (AOR = 4.8, with 95% CI 1.37–17.00). This finding was consistent [1, 39]. Besides, food outlets with large service were 9.6 times higher in good food safety practices than those with small service (AOR = 9.6, with 95% CI 2.2–42.1). On the other hand, food outlets which had married managers were 0.3 times less likely to be in good food safety practices than those food establishments which had single managers (AOR = 0.3, with 95% CI 0.11–0.93).

Furthermore, the odds of having good food safety practices among the food establishments with > 9 years’ experience were three times higher than those with ≤ 9 years' experience (AOR = 3, with 95% CI 1.03–8.76). This finding was similar to a study conducted by Teferi et al. [32]. Also, private or manager-owned food establishments had 3.5 times more likely to be in good food safety practices than those rented food establishments (AOR = 3.5, with 95% CI 1.21–10.32).

This study revealed that food outlets that had < 11 food handlers were 0.18 times less likely to be in good food safety practices than those food establishments which had ≥ 11 food handlers (AOR = 0.18, with 95% CI 0.05–0.60). In this study, only 51% of the food establishments had good food safety practices. This finding was lower than a study done by Alemayehu et al. [39].

Despite quality water being a key to reducing food and waterborne diseases everywhere, including at food establishments, a significant proportion of the food outlets' drinking-water samples were contaminated. From the evaluated samples of the food establishments, 29.5%, 16.8%, and 7.4% of the food outlets’ drinking-water samples were positive for total coliforms, fecal coliforms, and E. coli, respectively. These findings suggested that the probability of rising food and waterborne disease outbreaks in the food establishments was high and could cause cross-contamination. However, compared to a study conducted in Addis Ababa, the current findings are low [40]. Besides, this investigation revealed that 1.3% of the food establishments’ drinking-water samples had above-permissible levels of fluoride concentration that can cause dental fluorosis. However, this finding was very low compared to a study done in Ethiopia [41]. These variances can result from variations in the study design, the methods used to treat the water, or the availability of water safety training.

The current study indicated that only 51% of the food establishments had good food safety practices. This showed that, despite this outcome being better than a study conducted in Addis Ababa, poor food safety practices still pose a major threat to the public's health [30].

The current study indicated that 8.7% of the food outlets had no functional handwashing facilities in the kitchen. This can pose a tremendous public health problem. Also, a large number (18.8%) of the food outlets had no functional hand washing facilities near the toilet. We found that 22.8% of the food outlets had no septic tanks to manage liquid waste. Most importantly, 84.6% of the food outlet kitchen solid wastes' stayed inside the kitchen, still in final disposal. These results showed that the sanitation and hygiene condition of the food outlets were poor and might be a risk of disease outbreaks.

5 Conclusion

Identifying factors associated with food safety practices and determining the drinking water quality of food establishments are crucial to preventing food and waterborne diseases. Many vital factors influencing the food safety practice of food establishments were identified. Almost half of the food outlets had poor food safety practices, and many of the food outlets’ drinking-water samples were contaminated. A significant number of food outlets had no functional handwashing facilities. Therefore, food establishments should implement continuous monitoring and inspection systems to improve food safety practices. Furthermore, the food outlets should introduce and implement water treatment technologies and sanitation and hygiene improvement activities. In addition, the government should implement an effective regulatory system to improve the food safety practices, water quality, sanitation, and hygiene services of the food outlets.