Julia Liguori

Ursula Trübswasser

Rebecca Pradeilles

Agnès Le Port

Edwige Landais

Elise F Talsma

Mark Lundy

Christophe Béné

Nicolas Bricas

Amos Laar

Marie Josèphe Amiot

Inge D Brouwer

Michelle Holdsworth
email: michelle.holdsworth@ird.fr

Michelle Holdsworth

How do food safety concerns affect consumer behaviors and diets in low-and middle-income countries? A systematic review

Keywords:

ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

Introduction

Food safety (FS) concerns have increased as factors such as globalisation, urbanisation, increased disposable income and purchasing preferences continue to shift dietary patterns around the world. In low-and middle-income settings (LMICs), most foodborne diseases still stem from unsafe handling and preparation of fresh foods, such as animal sourced foods, fresh fruit and vegetables (FFV) (GP, 2016;[START_REF] Grace | Food safety in low and middle income countries[END_REF][START_REF] Grace | Safe Food, Fair Food: participatory risk analysis for improving the safety of informally produced and marketed food in sub-Saharan Africa[END_REF]. In 2010, foodborne hazards accounted for 600 million cases of foodborne disease and were estimated to be responsible for 420, 000 deaths annually in LMICs [START_REF] Havelaar | World health organization global estimates and regional comparisons of the burden of foodborne disease in 2010[END_REF]. As such, foodborne diseases account for an additional 33 million Disability Adjusted Life Years (DALYs) [START_REF] Havelaar | World health organization global estimates and regional comparisons of the burden of foodborne disease in 2010[END_REF].

Current literature suggests that FS concerns are occurring in every part of the food system; at production stages (unregulated use of pesticides, poor post-harvest handling), during processing (unregulated use of additives, contaminated water), during transportation, in the local food environment (unhygienic food outlets) or at the consumer level (unhygienic food preparation and storage practices) [START_REF] Kang'ethe | Food safety and public health implications of growing urban food markets[END_REF]. Food is unsafe when it is exposed to any hazard that makes it harmful to health, including bacterial, viral, parasitic and/or chemical toxins (FAO/WHO, 2003). Evidence suggests that financial gain or convenience of food preparation outweigh the risk associated with consuming a product [START_REF] Grace | Safe Food, Fair Food: participatory risk analysis for improving the safety of informally produced and marketed food in sub-Saharan Africa[END_REF], while fear of poor food hygiene could outweigh concerns about the nutritional quality of food [START_REF] Nago | Food safety is a key determinant of fruit and vegetable consumption in urban Beninese adolescents[END_REF][START_REF] Trubswasswer | Factors influencing obesogenic behaviours of adolescent girls and women in low-and middle-income countries: a qualitative evidence synthesis[END_REF]. The latter finding is worrisome as food safety and nutrition are potentially closely linked and concerns limiting the consumption of fresh FFV could make packaged (often ultra-processed) food, the perceived safer option [START_REF] Grace | Food safety: reducing and managing scares[END_REF][START_REF] Trubswasser | Assessing factors influencing adolescents' dietary behaviours in urban Ethiopia using participatory photography[END_REF]. While homecooked food is considered the safer and healthier option in LMIC settings [START_REF] Rao | Food safety knowledge, attitudes and practices of mothers: findings from focus group studies in South India[END_REF][START_REF] Trubswasswer | Factors influencing obesogenic behaviours of adolescent girls and women in low-and middle-income countries: a qualitative evidence synthesis[END_REF], eating out of home continues to increase especially in the urban context [START_REF] Reardon | The processed food revolution in african food systems and the double burden of malnutrition[END_REF]. Street food has become increasingly popular as it is perceived as accessible, affordable, and convenient, but can carry great risk if food safety management is not in place [START_REF] Abrahale | Street food research worldwide: a scoping review[END_REF][START_REF] Asiegbu | The food safety knowledge and microbial hazards awareness of consumers of ready-to-eat street-vended food[END_REF][START_REF] Gupta | A study on the street food dimensions and its effects on consumer attitude and behavioural intentions[END_REF][START_REF] Hoffmann | Food Safety in Low and Middle-Income Countries: the Evidence through an Economic Lens[END_REF]. These challenges are further compounded as food systems in many LMICs have limited regulatory, surveillance and control systems [START_REF] Grace | Food safety in low and middle income countries[END_REF][START_REF] Hoffmann | Food Safety in Low and Middle-Income Countries: the Evidence through an Economic Lens[END_REF][START_REF] Reardon | Links between supermarkets and food prices, diet diversity and food safety in developing countries[END_REF].

In addition to food safety challenges, food systems in LMICs are rapidly changing and have increasingly longer supply chains [START_REF] Reardon | The processed food revolution in african food systems and the double burden of malnutrition[END_REF]. Cheap, ultra-processed foods and beverages are widely available and advertised, especially in urban areas [START_REF] Baker | Ultraprocessed foods and the nutrition transition: global, regional and national trends, food systems transformations and political economy drivers[END_REF][START_REF] Dury | Food Systems at Risk: New Trends and Challenges[END_REF], impacting the nutritional quality of diets and the double burden of malnutrition [START_REF] Popkin | Dynamics of the double burden of malnutrition and the changing nutrition reality[END_REF]. This nutrition transition takes place as busy urban lives and limited incomes shift many consumers towards relying on cheap and convenient street foods, which are often nutrient poor (high in fat, sugar and salt) and unhygienic (GP, 2016;[START_REF] Makinde | Microbiological safety of ready-to-eat foods in low-and middle-income countries: a comprehensive 10-year (2009 to 2018) review[END_REF]. Furthermore, the livelihoods of small informal vendors, often women, could be jeopardised if small informal outlets are replaced with larger retail outlets [START_REF] Kawarazuka | Adapting to a new urbanizing environment: gendered strategies of Hanoi's street food vendors[END_REF][START_REF] Wertheim-Heck | Constrained consumer practices and food safety concerns in Hanoi[END_REF], 2019). Food safety scares may lead to stringent municipal authorities' policy and regulations, which might be neither feasible nor affordable for small and/or informal vendors (FAO, 2016).

Despite evidence that LMICs carry the majority of the foodborne disease burden [START_REF] Havelaar | World health organization global estimates and regional comparisons of the burden of foodborne disease in 2010[END_REF], most research on food safety has been conducted in high-income countries [START_REF] Redmond | Consumer food handling in the home: a review of food safety studies[END_REF][START_REF] Yeung | Food safety risk[END_REF][START_REF] Young | Barriers and facilitators to safe food handling among consumers: a systematic review and thematic synthesis of qualitative research studies[END_REF]. A recent evidence gap analysis of 1838 impact evaluations and 178 systematic reviews on the effects of food systems interventions on food security and nutrition outcomes in LMICs found only one study on food safety regulations [START_REF] Moore | The effects of food systems interventions on food security and nutrition outcomes in low-and middle-income countries[END_REF]. Food safety concerns in urban LMIC settings may differ from high-income settings, thus meriting further exploration. Evidence on the linkages between food safety concerns and consumer dietary behaviors in LMICs has not been previously synthesized. Based on this, we hypothesize that FS concerns could negatively impact consumer behavior and diet quality. Therefore, this review examined whether food safety concerns influence consumer behaviors/diets in LMICs (i.e., how unsafe FS exposures such as, hygiene, contamination and adulteration might influence consumer behavior and diets in LMICs) by synthesizing findings from quantitative, qualitative, and mixed-method studies. These findings will be key to design contextually appropriate policies that account for the identified drivers to contribute towards improving food safety and diets.

Conceptual framework linking exposures and outcomes

We used a framework to develop the coding structure for data extraction and guide analysis (Fig. 1). The focus of our research was consumer behaviors and diets within the wider food system (HLPE, 2017) and food safety concerns potentially influencing these behaviors. We reviewed existing frameworks and theories that conceptualized how different factors of food safety exposure might affect consumer behaviors and/or diets (FAO, 2016;[START_REF] Gfsp | Assuring Safe Food Systems: Policy Options for a Healthier Food Supply[END_REF]GP, 2016;[START_REF] Hlpe | Food Security and Nutrition: Building a Global Narrative towards[END_REF][START_REF] Osei-Kwasi | Factors influencing dietary behaviours in urban food environments in Africa: a systematic mapping review[END_REF]. None of the individual frameworks captured food safety exposure and consumer dietary behaviors sufficiently. We therefore deconstructed the concepts of the different frameworks and fitted the food safety factors within the different levels of influence (individual/household, social, physical and macro) using a socio-ecological approach [START_REF] Osei-Kwasi | Factors influencing dietary behaviours in urban food environments in Africa: a systematic mapping review[END_REF], 2021;[START_REF] Story | Creating healthy food and eating environments: policy and environmental approaches[END_REF]. For example, factors at the different levels include: cultural norms and food regulations (macro), availability and accessibility of (un)safe/(un)hygienic food (physical), family food practices (social), and knowledge of the issue and prior experience of foodborne disease (individual). A list of factors and the respective levels of influence can be found in the framework in Fig. 1.

The outcomes of the food safety factors were categorized into dietary behaviors (DBs), comprised of consumer behaviors (acquisition/ Fig. 1. Conceptual framework used to link the interactions between food safety exposures and consumer behaviors and diet outcomes. preparation/storage/meal practices) and diets (quality/quantity) guided by food systems (HLPE, 2017) and food safety (FAO, 2016) frameworks. Under potential outcomes, we also accounted for possible changes in behavior or substitutions due to FS concerns. Changes in consumer behaviors could include shifting the purchase to different vendors (DB1), changing the frequency of eating out (DB2) or the way food is prepared or stored (DB3). In terms of diets, individuals could adapt their diets due to food safety concerns by avoiding unsafe food, by consuming less nutritious foods or more ultra-processed packaged food (DB 4).

Methods

Review typology

A systematic review was conducted to appraise and synthesize existing evidence, identify research gaps in the evidence base and make recommendations for future research [START_REF] Grant | A typology of reviews: an analysis of 14 review types and associated methodologies[END_REF]. Following the PRISMA guidelines [START_REF] Rethlefsen | PRISMA-S: an extension to the PRISMA statement for reporting literature searches in systematic reviews[END_REF], the protocol was registered on the International prospective register of systematic review (available from PROSPERO 2020 CRD42020220617 https:// www.crd.york.ac.uk/prospero/display_record.php?Reco rdID=220617).

Inclusion and exclusion criteria

Qualitative, quantitative and mixed method study designs were considered for inclusion. Grey literature was also considered. Inclusion criteria for the review were study populations composed of males and females aged 10-18 years (adolescents) or 19-65 (adults) (if only part of the target group was covered, only attributable data to the selected target group was included). Studies had to be conducted in urban settings in countries classified as LMICs (using the World Bank definition of LMICs as of 2020) (World Bank Country and Lending Groups, 2020). Only studies that provided a clear link between FS exposure and a consumer behavior and/or dietary outcome were included. There was no restriction for date of publication. Among the excluded studies were: non-English publications, non-human or clinical populations, high income and rural-only settings and studies that investigated the association between food safety and consumers without a clear link with dietary behavior.

Information sources and search strategy

The search strategy was developed using the Population Exposure Context Outcome (PECO) model [START_REF] Morgan | Identifying the PECO: a framework for formulating good questions to explore the association of environmental and other exposures with health outcomes[END_REF] combining terms for Context (LMICs), Population (adolescent girls and boys, adult men and women aged 10-65 y), Exposure (food safety, food hygiene) and Outcome (consumer behavior and/or diets). Preliminary scoping searches were conducted to refine the search strategy, ensuring that relevant studies were identified with the search syntax. The final search syntax included text words and indexing terms specific for the different databases (e.g., MeSH for Pubmed). The search syntax was first developed for PubMed and then adapted to the additional database-specific search requirements. (Supplementary file 1: Search strategy).

A systematic search of PubMed, PsychInfo and Scopus was conducted on December 2, 2020. Google scholar was also searched for grey literature. Additional references were included from screening the references of included papers and their citations on Google scholar. An alert was created for new publications for all three databases. The search was updated on February 14, 2021 to include any recently published articles.

Screening

Complete references were imported and de-duplicated in Endnote X9.3.3. At the title, abstract and full text stage, JL and UT each screened all references with 20% double screened. Criteria for exclusion were recorded at every stage. In case of doubt, a reference was included in the next stage of reviewing. A third reviewer (ALP) independently screened 10% of excluded titles, abstracts and full texts.

Data extraction

Using a Google form, JL and UT extracted descriptive data including the first author; type of publication; year of publication; objectives; country where the study was conducted; study population (age, sample size, gender); research design; the type of dietary behavior; and the food safety dimensions (hygiene/contamination/adulteration at macro, physical, social or individual/household level) that the study assessed. The Google form extractions were converted into an excel file for further coding and analysis.

Quality appraisal

Each included study was critically appraised using a predefined list of criteria (n = 14 for quantitative studies, n = 10 for qualitative studies) [START_REF] Kmet | Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields[END_REF]. As Cochrane guidance advises against the use of scores [START_REF] Higgins | Assessment of Study Quality[END_REF], the original Kmet quality assessment tool was modified by replacing the score for each criterion (0, 1, 2) with low quality/red (high risk of bias), medium quality/yellow, and high quality/green (low risk of bias).

Two authors (JL andUT) independently conducted quality appraisals of all included papers. ALP and EL checked 10% of the appraisals. Discrepancies in the rating were discussed until agreement was reached. Studies were not excluded based on the quality appraisal. (Supplementary file 2: Quality assessment).

Data synthesis

Analysis was first undertaken for every exposure and outcome individually. During this process, the conceptual framework (Fig. 1) was used to summarize themes related to influencing factors at the socioecological levels (macro, physical, social, individual/household level) and food acquisition and consumption behavior outcomes (Supplementary file 3: Framework for coding). Extractions were analyzed to develop a theory-based and data driven codebook to create the final list of DBs. The full data set was recoded to directly link the exposures with one behavioral outcome by JL, MH, RP and UT. During this stage, relevant quotes were identified for every link and short memos on findings and points for discussion were logged in a research diary. The results are presented in the following order for each identified level on influence of factors on dietary behavior: macro, physical, social and individual/household.

Results

In total, 46 studies met the inclusion criteria for this study (Fig. 2). Included studies were published between 2003 and 2021, with over half published after 2016 (n = 28). Twenty-two studies used qualitative methods (48%), 14 quantitative (30%) and the remaining 10 studies (22%) applied mixed methods.

Study characteristics

An overview of key study characteristics is given in Table 1. The included studies spanned 20 different LMICs (Fig. 3). Africa and the East Asia and Pacific region had the most publications (n = 6 respectively) followed by Latin America and the Caribbean (n = 4); South Asia (n = 2); Europe and Central Asia (n = 1); and Middle East and North Africa (n = 1). Twenty-three studies (50%) were conducted in upper-middle income countries, 20 studies (43%) in low-middle income countries, while only three studies (7%) were conducted in low-income countries. Nine studies focused on adolescents (10-19 years), 20 on adults (18-65) and 11 had mixed age populations. The remaining six studies mentioned adults or adolescents in the text, but did not provide exact age, only age ranges.

Quality appraisal

The quality appraisal revealed that, out of the 29 qualitative studies, the majority of them (n = 25) failed to demonstrate reflexivity and/or to report verification procedures (n = 10) used to make the study more robust. Of the 24 quantitative studies, some failed to report/reported poorly on methods used for subject selection (n = 8), sample size (n = 8), estimate of variance (n = 10) and well-defined outcome measures (n = 12).

Food safety factors influencing what food consumers purchase (DB1)

Freshness and shelf life of FFV, and expiration dates on packaged goods determined which food was perceived as safe [START_REF] Cheng | Consumers' behaviors and concerns on fresh vegetable purchase and safety in Beijing urban areas, China[END_REF][START_REF] Zorba | Consumer food safety perceptions and practices in a Turkish community[END_REF]. FS knowledge, prior experience of FDB and fear that food was unsafe led consumers to smell or assess the foods' appearance before purchase [START_REF] Ha | Food risk in consumers' eye and their consumption responses: evidence from Hanoi survey[END_REF][START_REF] Kendall | Chinese consumer's attitudes, perceptions and behavioural responses towards food fraud[END_REF][START_REF] Maitiniyazi | Understanding Chinese consumers' safety perceptions of dairy products: a qualitative study[END_REF][START_REF] Stanton | Changing consumer preferences in emerging markets: food market challenges in Central Mexico[END_REF]. Vietnamese participants pointed out that those who had prior foodborne disease experience were less confident when selecting safe produce (Wertheim-Heck and Spaargaren, 2015). Consumers in China who purchased vegetables regularly, reported paying more attention to vegetable safety compared to less regular purchasers [START_REF] Cheng | Consumers' behaviors and concerns on fresh vegetable purchase and safety in Beijing urban areas, China[END_REF]. Some evidence suggested that limited FS knowledge restricted acquisition of safer foods: "I can't In Ecuador [START_REF] April | Characteristics and motivations of consumers of direct purchasing channels and the perceived barriers to alternative food purchase: a crosssectional study in the Ecuadorian andes[END_REF], purchasing of organic or certified foods was widespread, while in China [START_REF] Cheng | Consumers' behaviors and concerns on fresh vegetable purchase and safety in Beijing urban areas, China[END_REF], purchase of organic foods was limited by price and availability. Study participants in China and Vietnam were motivated to grow their own vegetables to ensure their own access to safe vegetable [START_REF] Ha | Food risk in consumers' eye and their consumption responses: evidence from Hanoi survey[END_REF][START_REF] Kendall | Chinese consumer's attitudes, perceptions and behavioural responses towards food fraud[END_REF][START_REF] Pham | If I want safe food I have to grow it myself': patterns and motivations of urban agriculture in a small city in Vietnam's northern borderlands[END_REF]Wertheim-Heck et al., 2015): "In recent years, where have all the diseases, especially cancers, come from? Because of dirty food! We try our best to get clean food for our children's families and our grandchildren" [Male, early 50s, Vietnam] (Pham and Turner, 2020).

Food safety factors influencing where (retailers) consumers purchase (DB1)

Consumers in Ecuador [START_REF] April | Characteristics and motivations of consumers of direct purchasing channels and the perceived barriers to alternative food purchase: a crosssectional study in the Ecuadorian andes[END_REF], Turkey [START_REF] Ergönül | Consumer awareness and perception to food safety: a consumer analysis[END_REF] and Vietnam [START_REF] Wertheim-Heck | Constrained consumer practices and food safety concerns in Hanoi[END_REF] reported shifting their points of purchase to small-scale producers, where they had less concerns about pesticide contamination. Different studies in Vietnam and Ethiopia suggested that traditional food outlets, such as markets or informal vendors, were considered to be less safe, but more accessible by consumers [START_REF] Ha | Food risk in consumers' eye and their consumption responses: evidence from Hanoi survey[END_REF][START_REF] Pham | If I want safe food I have to grow it myself': patterns and motivations of urban agriculture in a small city in Vietnam's northern borderlands[END_REF][START_REF] Trubswasser | Assessing factors influencing adolescents' dietary behaviours in urban Ethiopia using participatory photography[END_REF][START_REF] Wertheim-Heck | Constrained consumer practices and food safety concerns in Hanoi[END_REF][START_REF] Grace | Food safety in low and middle income countries[END_REF], 2019): "If they sold officially certified safe vegetables near here, then I would buy them frequently" [Adult, Vietnam] ( [START_REF] Wertheim-Heck | Constrained consumer practices and food safety concerns in Hanoi[END_REF]. Three studies highlighted that trust was stronger for local produce, as consumers reported shifting their points of purchase to small-scale producers [START_REF] April | Characteristics and motivations of consumers of direct purchasing channels and the perceived barriers to alternative food purchase: a crosssectional study in the Ecuadorian andes[END_REF][START_REF] Ergönül | Consumer awareness and perception to food safety: a consumer analysis[END_REF][START_REF] Wertheim-Heck | Constrained consumer practices and food safety concerns in Hanoi[END_REF], including making the effort to travel to more rural areas to purchase safer food (animal sourced products and vegetables) [START_REF] Ha | Food risk in consumers' eye and their consumption responses: evidence from Hanoi survey[END_REF]Wertheim-Heck and Spaargaren, 2015): "One of my classmates sells organic vegetables or organic agricultural products […] All the animals in there are feed by coarse cereals. I went to her farms for one time. I totally trust that kind of farms" [Female, adult, China] ( [START_REF] Kendall | Chinese consumer's attitudes, perceptions and behavioural responses towards food fraud[END_REF].

Consumers assessed the cleanliness and tidiness of food outlets [START_REF] April | Characteristics and motivations of consumers of direct purchasing channels and the perceived barriers to alternative food purchase: a crosssectional study in the Ecuadorian andes[END_REF] along with food handlers' practices, food displays, packaging and climate controls, such as in-store refrigeration, before making a purchase at a food outlet [START_REF] Knight | Household food safety awareness of selected urban consumers in Jamaica[END_REF]. The supermarket was widely cited as a safe food outlet in several countries [START_REF] Behrens | Consumer purchase habits and views on food safety: a Brazilian study[END_REF][START_REF] Cheng | Consumers' behaviors and concerns on fresh vegetable purchase and safety in Beijing urban areas, China[END_REF][START_REF] Kendall | Chinese consumer's attitudes, perceptions and behavioural responses towards food fraud[END_REF][START_REF] Knight | Household food safety awareness of selected urban consumers in Jamaica[END_REF][START_REF] Maitiniyazi | Understanding Chinese consumers' safety perceptions of dairy products: a qualitative study[END_REF][START_REF] Wertheim-Heck | Food safety and nutrition for lowincome urbanites: exploring a social justice dilemma in consumption policy[END_REF]: "I come here [supermarket] every day, I worry about food safety, but here [supermarket] it is easy to find safe products" [Adult, Vietnam] ( Wertheim-Heck et al., 2015). Yet, the safe foods offered in the supermarket were also perceived as more expensive and less fresh [START_REF] Wertheim-Heck | Food safety and nutrition for lowincome urbanites: exploring a social justice dilemma in consumption policy[END_REF]. In China, participants purchased products at national and international supermarket chains, which were generally perceived as "trusted retailers" despite higher prices (Kendall, 2018). Concerns about FS were higher among Chinese consumers who spent more of their income on food and were able to afford to shop at supermarkets [START_REF] Liu | Chinese consumers food purchasing behaviors and awareness of food safety[END_REF]. Evidence from Vietnam reported that lower socio-economic (SES) consumers could not afford to shop at supermarkets: ''With my salary, I can't afford to shop at the supermarket. I know that vegetables are safe and guaranteed, but they cost twice as much as outside [at the markets]" [Vietnam] [START_REF] Figuié | Market appeal in an emerging economy: supermarkets and poor consumers in Vietnam[END_REF]. Poorer consumers were therefore dependent on traditional food vendors [START_REF] Knight | Household food safety awareness of selected urban consumers in Jamaica[END_REF]Wertheim-Heck and Spaargaren, 2015;Wertheim-Heck et al., 2015).

Social ties, including advice from family and peers influenced acquisition of safe foods (Wertheim-Heck and Spaargaren, 2015). Building a rapport and gaining trust in a food vendor, especially in informal food outlets was mentioned in different countries as a mean of unsafe food due to lack of alternatives/substituting unsafe food with other food (less fresh fruit/veg, more processed packaged food, more fried food, more non-nutritious food).

reducing risk and improving safety [START_REF] Behrens | Consumer purchase habits and views on food safety: a Brazilian study[END_REF][START_REF] Figuié | Sustainable development of peri-urban agriculture in South-East Asia project. Vegetable consumption behaviour in Vietnam[END_REF][START_REF] Ha | Food risk in consumers' eye and their consumption responses: evidence from Hanoi survey[END_REF][START_REF] Kendall | Chinese consumer's attitudes, perceptions and behavioural responses towards food fraud[END_REF][START_REF] Pham | If I want safe food I have to grow it myself': patterns and motivations of urban agriculture in a small city in Vietnam's northern borderlands[END_REF][START_REF] Stanton | Changing consumer preferences in emerging markets: food market challenges in Central Mexico[END_REF][START_REF] Wertheim-Heck | Constrained consumer practices and food safety concerns in Hanoi[END_REF][START_REF] Grace | Food safety in low and middle income countries[END_REF]. One consumer highlighted this importance: "Some months ago, I moved to this area. Before I had my regular vendor, but also here I searched for a good vendor and was lucky to find my new vendor. She advises me on what is safe and fresh to buy" [Adult, Vietnam] (Wertheim-Heck et al., 2015). Purchasing animal sourced products from trusted butchers was also a strategy used to ensure food safety (Kendall, 2018;[START_REF] Zorba | Consumer food safety perceptions and practices in a Turkish community[END_REF].

Food safety factors influencing eating out of home behaviors

In Asia, consumer concerns about food safety, including pesticides, chemicals and hormones in foods were also linked with eating out less often in [START_REF] Kendall | Chinese consumer's attitudes, perceptions and behavioural responses towards food fraud[END_REF][START_REF] Phulkerd | Characterizing urban home gardening and associated factors to shape fruit and vegetable consumption among non-farmers in Thailand[END_REF]: "I feel nowadays many people have abused to use hormone and chemical […] so I am trying to only cook and eat at home" [Male, China] ( [START_REF] Kendall | Chinese consumer's attitudes, perceptions and behavioural responses towards food fraud[END_REF]. Increased awareness about food safety risks and/or nutrition was also linked with eating out less often in Africa [START_REF] Nago | Food safety is a key determinant of fruit and vegetable consumption in urban Beninese adolescents[END_REF][START_REF] Trubswasser | Assessing factors influencing adolescents' dietary behaviours in urban Ethiopia using participatory photography[END_REF] and Asia [START_REF] Blum | In-depth assessment of snacking behaviour in unmarried adolescent girls 16-19 years of age living in urban centres of Java, Indonesia[END_REF][START_REF] Ha | Food risk in consumers' eye and their consumption responses: evidence from Hanoi survey[END_REF][START_REF] Hiamey | Street food consumption in a Ghanaian Metropolis: the concerns determining consumption and non-consumption[END_REF][START_REF] Hu | Association between eating out and socio-demographic factors of university students in chongqing, China[END_REF][START_REF] Lachat | Factors associated with eating out of home in Vietnamese adolescents[END_REF][START_REF] Liu | Chinese consumers food purchasing behaviors and awareness of food safety[END_REF][START_REF] Phulkerd | Characterizing urban home gardening and associated factors to shape fruit and vegetable consumption among non-farmers in Thailand[END_REF][START_REF] Sondari | Eating behaviour of adolescent schoolgirls in Malang, East Java: a qualitative study[END_REF].

Participants described additional food safety factors in their physical environment influenced their choice of food outlets. This link was observed in 14 studies across Africa [START_REF] Adam | Students' food safety concerns and choice of eating place in Ghana[END_REF][START_REF] Boatemaa | Food beliefs and practices in urban poor communities in Accra: implications for health interventions[END_REF][START_REF] Hiamey | Street food consumption in a Ghanaian Metropolis: the concerns determining consumption and non-consumption[END_REF][START_REF] Ramaroson Rakotosamimanana | Studying the nutritional beliefs and food practices of Malagasy school children parents. A contribution to the understanding of malnutrition in Madagascar[END_REF][START_REF] Rheinlander | Keeping up appearances: perceptions of street food safety in urban Kumasi, Ghana[END_REF], Asia [START_REF] Fatimah | Foodservice hygiene factors-the consumer perspective[END_REF][START_REF] Hu | Association between eating out and socio-demographic factors of university students in chongqing, China[END_REF][START_REF] Li | Enablers and barriers to improving worksite canteen nutrition in Pudong, China: a mixed-methods formative research study[END_REF][START_REF] Liu | Chinese consumers food purchasing behaviors and awareness of food safety[END_REF][START_REF] Nguyen | Customers' knowledge, attitude, and practices towards food hygiene and safety standards of handlers in food facilities in Hanoi, Vietnam[END_REF][START_REF] Veeck | Influences on food choices of urban Chinese teenagers[END_REF][START_REF] Zorba | Consumer food safety perceptions and practices in a Turkish community[END_REF] and South America [START_REF] Valente | Profile of food truck consumers and their opinion about food safety[END_REF][START_REF] Verstraeten | A conceptual framework for healthy eating behavior in ecuadorian adolescents: a qualitative study[END_REF]. Food hygiene in outlets was of particular concern: "[…] Sanitation includes but is not limited to a fresh smell in the restaurant, a clean-looking kitchen, and clean chairs and tables. You should routinely check whether there are hairs and other stuff in the food, and whether the food was washed" [Male, 16 years, China] [START_REF] Veeck | Influences on food choices of urban Chinese teenagers[END_REF].

Safety concerns extended to where food was prepared, cooked and sold. This illustrated that not only the hygiene of the immediate food setting matters, but also the environment surrounding the vendor was of importance. When Chinese consumers ate out of home, 48.5% reported buying food after assessing the hygiene of the vendor and of the surrounding premises [START_REF] Liu | Chinese consumers food purchasing behaviors and awareness of food safety[END_REF]. Participants in Ghana [START_REF] Adam | Students' food safety concerns and choice of eating place in Ghana[END_REF][START_REF] Boatemaa | Food beliefs and practices in urban poor communities in Accra: implications for health interventions[END_REF][START_REF] Rheinlander | Keeping up appearances: perceptions of street food safety in urban Kumasi, Ghana[END_REF]) also used FS awareness and prior experience of foodborne disease to assess the hygiene of a food outlet: "there is rubbish at where she is cooking, that is how you would know that the food you will be buying is not good and it will bring you diseases so it's not good for you" [Adult, Ghana] [START_REF] Boatemaa | Food beliefs and practices in urban poor communities in Accra: implications for health interventions[END_REF]. Participants in Ghana that were concerned about food outlet/vendor hygiene were also more likely to eat at restaurants as opposed to bush canteens [informal eateries] [START_REF] Adam | Students' food safety concerns and choice of eating place in Ghana[END_REF]. Studies in Malaysia and Vietnam also reported on attention paid to the food environment's immediate hygiene, but observed that freshness, displays or food served led consumers to visit these locations more often [START_REF] Fatimah | Foodservice hygiene factors-the consumer perspective[END_REF][START_REF] Nguyen | Customers' knowledge, attitude, and practices towards food hygiene and safety standards of handlers in food facilities in Hanoi, Vietnam[END_REF].

Street food was generally distrusted and viewed as low quality when compared with home-cooked food: "In fact the quality of food bought outside the homes can never be compared to food prepared at home. I only buy food from outside my home when and only when I fail to cook at home" [Male, Ghana] [START_REF] Rheinlander | Keeping up appearances: perceptions of street food safety in urban Kumasi, Ghana[END_REF]. In Turkey, only 2% of participants believed that food sold by street vendors are safe [START_REF] Zorba | Consumer food safety perceptions and practices in a Turkish community[END_REF]. The vast majority (97.4%) of food truck consumers from a study in Brazil reported that hygiene at and around the food truck was important, stating that they (particularly men) would be willing to pay more to have safe, hygienic dishes [START_REF] Valente | Profile of food truck consumers and their opinion about food safety[END_REF]. Factors like high prices and/or poor quality at school canteens have led students to shift their purchase to food outlets outside of the school [START_REF] Veeck | Influences on food choices of urban Chinese teenagers[END_REF]. Respondents also selected food outlets based on reputation or trust and not on observations of safe food handling practices [START_REF] Rheinlander | Keeping up appearances: perceptions of street food safety in urban Kumasi, Ghana[END_REF]. Yet, other studies in China [START_REF] Hu | Association between eating out and socio-demographic factors of university students in chongqing, China[END_REF][START_REF] Liu | Urban street foods in Shijiazhuang city, China: current status, safety practices and risk mitigating strategies[END_REF], Turkey [START_REF] Sanlier | Evaluation of food purchasing behaviour of consumers from supermarkets[END_REF][START_REF] Zorba | Consumer food safety perceptions and practices in a Turkish community[END_REF], Ghana [START_REF] Rheinlander | Keeping up appearances: perceptions of street food safety in urban Kumasi, Ghana[END_REF], India [START_REF] Correa | Perceptions of healthy eating amongst Indian adolescents in India and Canada[END_REF], Indonesia [START_REF] Sondari | Eating behaviour of adolescent schoolgirls in Malang, East Java: a qualitative study[END_REF] and South Africa [START_REF] Hunter-Adams | Food insecurity in relation to obesity in peri-urban Cape Town, South Africa: implications for diet-related noncommunicable disease[END_REF] found that consumers still take risks and continue purchasing from questionable street vendors. Affordability, preference and taste were important factors that drove consumers to maintain their eating out choices: "We will have the road side vendors food, it's not safe having because it's open food and we don't know how they made it but it just tempts us" [Female, adolescent, India] [START_REF] Correa | Perceptions of healthy eating amongst Indian adolescents in India and Canada[END_REF].

Indonesian mothers were reported to encourage family members to eat meals, especially breakfast, at home to reduce exposure to foodborne disease risk, as food vendors and their goods were perceived to be unhygienic [START_REF] Blum | In-depth assessment of snacking behaviour in unmarried adolescent girls 16-19 years of age living in urban centres of Java, Indonesia[END_REF]. Parents in Madagascar distrusted small restaurants, also preferring meal preparation at home [START_REF] Ramaroson Rakotosamimanana | Studying the nutritional beliefs and food practices of Malagasy school children parents. A contribution to the understanding of malnutrition in Madagascar[END_REF]. Another study suggested that women were influenced by their husbands to eat out more often, despite their own food safety concerns: "my husband likes food from outside, so I also started eating outside food" [Female, 28 years, India] [START_REF] Bailey | Food choice drivers in the context of the nutrition transition in Delhi, India[END_REF].

Food safety factors influencing food preparation and storage behaviors

Participants reported that food safety during meal preparation was important to keep their families safe [START_REF] Kendall | Chinese consumer's attitudes, perceptions and behavioural responses towards food fraud[END_REF][START_REF] Knight | Household food safety awareness of selected urban consumers in Jamaica[END_REF][START_REF] Pham | If I want safe food I have to grow it myself': patterns and motivations of urban agriculture in a small city in Vietnam's northern borderlands[END_REF]Wertheim-Heck and Spaargaren, 2015;Wertheim-Heck et al., 2015). Participants' actual or perceived knowledge of how foods are produced influenced food preparation and storage practices at home [START_REF] Lagerkvist | How consumer confidence in food safety practices along the food supply chain determines food handling practices: evidence from Ghana[END_REF][START_REF] Li | Enablers and barriers to improving worksite canteen nutrition in Pudong, China: a mixed-methods formative research study[END_REF][START_REF] Nago | Food safety is a key determinant of fruit and vegetable consumption in urban Beninese adolescents[END_REF][START_REF] Wertheim-Heck | Constrained consumer practices and food safety concerns in Hanoi[END_REF]Wertheim-Heck and Spaargaren, 2015;[START_REF] Yiga | Determinants of dietary and physical activity behaviours among women of reproductive age in urban Uganda, a qualitative study[END_REF].

Participants reported that cooking vegetables was time consuming and difficult, due to the preparation methods required to ensure safety, but pre-packaged vegetables from vendors were not prioritized as they were also deemed to be unhygienic [START_REF] Yiga | Determinants of dietary and physical activity behaviours among women of reproductive age in urban Uganda, a qualitative study[END_REF]. One study in Vietnam demonstrated that social factors, such as an established relationship with vegetable vendors, could reduce time spent on food preparation at home: "If the seller has already washed the vegetables, I even don't have to do that myself" [Adult, Vietnam] ( [START_REF] Wertheim-Heck | Constrained consumer practices and food safety concerns in Hanoi[END_REF]. In Mexico [START_REF] Stanton | Changing consumer preferences in emerging markets: food market challenges in Central Mexico[END_REF] and Vietnam [START_REF] Wertheim-Heck | Constrained consumer practices and food safety concerns in Hanoi[END_REF], consumers reported that when they could not prepare food themselves, they looked for the most unprocessed item on the market to replace it to reduce risk.

The availability of water at home influenced the level of hygiene during food preparation in Ethiopia: "If there's no water available when we prepare food, we might just peel the garlic and use it without washing it" [Male, 17 years, Ethiopia] [START_REF] Trubswasser | Assessing factors influencing adolescents' dietary behaviours in urban Ethiopia using participatory photography[END_REF]. Using refrigeration, freezing and/or eating food soon after preparation were all cited as practices utilized to prevent safety risks within the home in Jamaica [START_REF] Knight | Household food safety awareness of selected urban consumers in Jamaica[END_REF] and Vietnam (Wertheim-Heck and Spaargaren, 2015). Study participants in several countries described techniques used to clean fruit and vegetables to make them safer to eat. Washing hands before preparing food, washing produce before eating and using clean water for cooking was observed in Nepal [START_REF] Pahlm | Physical activity and diet among adolescents of Kathmandu, Nepal: knowledge and attitudes[END_REF] and detailed by a participant in Madagascar: "When meals are served, the plates have been previously cleaned well, hands should be washed … that's cleanliness" [Student, Madagascar] [START_REF] Ramaroson Rakotosamimanana | Studying the nutritional beliefs and food practices of Malagasy school children parents. A contribution to the understanding of malnutrition in Madagascar[END_REF]. Individuals in Vietnam were confident in their own food preparation practices, such as soaking and washing vegetables, and therefore believed that food prepared at home was generally safe [START_REF] Figuié | Sustainable development of peri-urban agriculture in South-East Asia project. Vegetable consumption behaviour in Vietnam[END_REF].

Food safety factors influencing the nutritional quality of dietsconsumption of nutritious foods

Studies in Turkey [START_REF] Ergönül | Consumer awareness and perception to food safety: a consumer analysis[END_REF], Myanmar [START_REF] Downs | The interface between consumers and their food environment in Myanmar: an exploratory mixed-methods study[END_REF], Uganda [START_REF] Yiga | Determinants of dietary and physical activity behaviours among women of reproductive age in urban Uganda, a qualitative study[END_REF] and Vietnam [START_REF] Pham | If I want safe food I have to grow it myself': patterns and motivations of urban agriculture in a small city in Vietnam's northern borderlands[END_REF] reported that consumers are afraid to eat fresh fruit and vegetables due to fear of chemical fertilizers and pesticides used during production. One participant stated: "the tomatoes, the cabbages, they grow up on pesticides, everything is sprayed with pesticides. Yes, even though we would like to eat them but when we think about the pesticides, we leave them" [Female, Uganda] [START_REF] Yiga | Determinants of dietary and physical activity behaviours among women of reproductive age in urban Uganda, a qualitative study[END_REF]. Therefore, home gardening was preferred among consumers, for example, it was reported to be associated with sufficient FFV intake in Thailand [START_REF] Yiga | Determinants of dietary and physical activity behaviours among women of reproductive age in urban Uganda, a qualitative study[END_REF]. In a household survey in Vietnam, participants reported eating less vegetables due to food safety concerns (Wertheim-Heck et al., 2015). Yet, another study in Vietnam noted that fear of pesticides did not necessarily lead to a change in vegetable consumption, as participants believed in the high nutrient quality of vegetables [START_REF] Figuié | Sustainable development of peri-urban agriculture in South-East Asia project. Vegetable consumption behaviour in Vietnam[END_REF].

In Benin and Ethiopia, diet quality was influenced by the hygiene of the food outlet/vendor or food presentation, with unclean food outlets or environments acting as a barrier for fruit and vegetable consumption for adolescents [START_REF] Nago | Food safety is a key determinant of fruit and vegetable consumption in urban Beninese adolescents[END_REF][START_REF] Trubswasser | Assessing factors influencing adolescents' dietary behaviours in urban Ethiopia using participatory photography[END_REF]. A student described the influence family advice can have on dietary intake: "if you want to eat mangoes or pineapple, daddy or mummy would tell you not to eat […] you will have diarrhea or something [another disease]. Otherwise, when I wake up and see a fruit, I eat it" [Male, student, Benin] [START_REF] Nago | Food safety is a key determinant of fruit and vegetable consumption in urban Beninese adolescents[END_REF].

In addition to fruit and vegetables, the consumption of animal sourced foods was also influenced by food safety concerns. In Jamaica, 68% of survey participants reported discontinued purchase of meat, poultry and dairy products due to food safety concerns [START_REF] Knight | Household food safety awareness of selected urban consumers in Jamaica[END_REF]. In Turkey, consumers also mitigated perceived risk of chemicals (pesticides and hormones) by reducing their consumption of fish and poultry [START_REF] Ergönül | Consumer awareness and perception to food safety: a consumer analysis[END_REF]. Participants in China who had prior experience with food borne disease were also more likely to consume less animal sourced proteins [START_REF] Liu | Chinese consumers food purchasing behaviors and awareness of food safety[END_REF].

Food safety factors influencing the nutritional quality of dietsconsumption of ultra-processed packaged foods

Concerns about food adulteration, hygiene of food outlets/vendors, food presentation, perceived freshness of food and family safety concerns led study participants in Benin, Brazil, Ethiopia, Indonesia, Iran, Mexico and Turkey to prefer packaged foods [START_REF] Bastami | Factors behind healthy snack consumption at school among high-school students: a qualitative study[END_REF][START_REF] Behrens | Consumer purchase habits and views on food safety: a Brazilian study[END_REF][START_REF] Blum | In-depth assessment of snacking behaviour in unmarried adolescent girls 16-19 years of age living in urban centres of Java, Indonesia[END_REF][START_REF] Ergönül | Consumer awareness and perception to food safety: a consumer analysis[END_REF][START_REF] Nago | Food safety is a key determinant of fruit and vegetable consumption in urban Beninese adolescents[END_REF][START_REF] Stanton | Changing consumer preferences in emerging markets: food market challenges in Central Mexico[END_REF][START_REF] Trubswasser | Assessing factors influencing adolescents' dietary behaviours in urban Ethiopia using participatory photography[END_REF]. For example, in Iran, students bought pre-packaged foods because they did not want to worry about the hygiene of food sold by street vendors: "a snack which is produced by dirty hands contains microbes and can cause illness […] Therefore, I prefer packed puffs and chips to traditional bread and cheese because they are safer" [Female, student, Iran] [START_REF] Bastami | Factors behind healthy snack consumption at school among high-school students: a qualitative study[END_REF]. Study participants from Ethiopia used food labels to decide if food was clean, which in turn increased their preference for packaged foods [START_REF] Trubswasser | Assessing factors influencing adolescents' dietary behaviours in urban Ethiopia using participatory photography[END_REF]. Mothers in Indonesia [START_REF] Blum | In-depth assessment of snacking behaviour in unmarried adolescent girls 16-19 years of age living in urban centres of Java, Indonesia[END_REF] and Mexico [START_REF] Stanton | Changing consumer preferences in emerging markets: food market challenges in Central Mexico[END_REF] also bought more packaged snacks for their families to avoid unsafe products.

While many studies show a preference for packaged foods, some consumers within these studies, Mexico [START_REF] Stanton | Changing consumer preferences in emerging markets: food market challenges in Central Mexico[END_REF] and Brazil [START_REF] Behrens | Consumer purchase habits and views on food safety: a Brazilian study[END_REF], expressed concerns about packaged food as potentially adulterated or expired, preferring to buy unprocessed food at wet markets: "Packaged on January, 19th. I can't believe it! They say the product is fresh but the shelf-life could have been altered" [Female, Brazil] ( [START_REF] Behrens | Consumer purchase habits and views on food safety: a Brazilian study[END_REF].

Discussion

This review aimed to synthesize evidence on how food safety might influence consumer behaviors and diets in LMICs. The studies included in this review reflect a growing interest for food safety research in LMICs in recent years. Evidence from our review suggests that food safety concerns, such as fears about contamination from pesticides from agricultural production, hygiene in and around food outlets, kinship networks with vendors and household level practices influence where consumers acquire, purchase or consume food.

Strengths and limitations

Our review followed a rigorous systematic review methodology [START_REF] Rethlefsen | PRISMA-S: an extension to the PRISMA statement for reporting literature searches in systematic reviews[END_REF], searching three databases to identify relevant peer-reviewed quantitative, qualitative and mixed methods studies. Constructing a novel analytical framework allowed us to fit food safety factors within the different levels of influence (macro, physical, social, individual/household levels) of a socio-ecological framework. This enabled us to review consumers' behaviors and diets, which often go unacknowledged. Our close look at the linkages between exposure and outcome, allowed a more nuanced understanding of the mechanisms through which food safety influences what people purchase or consume. The last noticeable strength of this study is the fact that we only considered studies that had data presenting a direct link between a food safety exposure and an outcome related to consumer behaviors or diets.

This approach however also means that 123 studies that discussed food safety in LMICs, but only reported on food safety factors without a dietary behavior outcome of interest, were not included. Finally limiting the language to English means that relevant literature in other languages were excluded.

Food safety findings and discussion

We found evidence that consumers change food acquisition patterns due to FS concerns. Although eating out of home is a common practice in LMICs, the review indicates that consumers may avoid or reduce eating out because of FS concerns. In contrast, home grown and home cooked food was regarded as safe and nutritious (even if this cannot be verified within the scope of the review). Despite their knowledge and concern, some consumers continue to eat out of home either due to lack of choice or preference for street food. In addition, easy access, low prices and convenience of street food can be more important or even outweigh consumers' concerns related to food safety.

FS practices in the home, such as hygienic preparation of vegetables and proper storage methods, are widely used as a way to ensure that food is safe to eat. However, time required to prepare food safely is often cited as a barrier [START_REF] Rheinlander | Keeping up appearances: perceptions of street food safety in urban Kumasi, Ghana[END_REF][START_REF] Yiga | Determinants of dietary and physical activity behaviours among women of reproductive age in urban Uganda, a qualitative study[END_REF]. In addition, diet quality might decrease as a result of FS concerns, because consumers purchase and consume less perishable foods, such as fruit and vegetables. While packaged foods are not all nutritionally poor, several references were made to preferences for foods with ultra-processed ingredients.

Recent literature suggests that traditional consumers' mitigation strategies to decrease microbiological risk, such as boiling milk [START_REF] Roesel | Food Safety and Informal Markets: Animal Products in Subsaharan Africa[END_REF] are no longer as efficient when consumers are presented with increased supplies of ultra-processed/packaged foods. Therefore, consumers must evaluate and manage food safety related risks, with little information or knowledge on the subject. Expressing their concerns over pesticide use in food production, consumers appeared to lack trust in the food system [START_REF] Ha | Food risk in consumers' eye and their consumption responses: evidence from Hanoi survey[END_REF][START_REF] Veeck | Influences on food choices of urban Chinese teenagers[END_REF]. This could be due to consumers not trusting national regulations or ineffective risk communication strategies, designed to increase food safety understanding/minimize consumer risk, but failing to do so. In order to regain some control over their nutrition and health [START_REF] Roesel | Food Safety and Informal Markets: Animal Products in Subsaharan Africa[END_REF], consumers mention forming friendships with vendors. Consumers often cited purchasing from trusted vendors as a way to mitigate these concerns [START_REF] Behrens | Consumer purchase habits and views on food safety: a Brazilian study[END_REF][START_REF] Figuié | Sustainable development of peri-urban agriculture in South-East Asia project. Vegetable consumption behaviour in Vietnam[END_REF][START_REF] Ha | Food risk in consumers' eye and their consumption responses: evidence from Hanoi survey[END_REF][START_REF] Kendall | Chinese consumer's attitudes, perceptions and behavioural responses towards food fraud[END_REF][START_REF] Pham | If I want safe food I have to grow it myself': patterns and motivations of urban agriculture in a small city in Vietnam's northern borderlands[END_REF][START_REF] Rheinlander | Keeping up appearances: perceptions of street food safety in urban Kumasi, Ghana[END_REF][START_REF] Stanton | Changing consumer preferences in emerging markets: food market challenges in Central Mexico[END_REF][START_REF] Wertheim-Heck | Constrained consumer practices and food safety concerns in Hanoi[END_REF][START_REF] Grace | Food safety in low and middle income countries[END_REF]. As safe food items are purchased over an extended period, trusted vendors become a safeguard and are a more tangible way for consumers to reduce risk than trusting in national regulations within the food system.

As formal food outlets, such as supermarkets/formal markets often have private food safety checks and standards, consumers perceive food sold in these settings to be safer than those sold in informal settings [START_REF] Reardon | Links between supermarkets and food prices, diet diversity and food safety in developing countries[END_REF][START_REF] Roesel | Food Safety and Informal Markets: Animal Products in Subsaharan Africa[END_REF]. Despite this notion, there is a paucity of evidence on the quality of food safety in different outlets [START_REF] Marshall | Building a global food systems typology: a new tool for reducing complexity in food systems analysis[END_REF]. Some middle-class consumers in China and Vietnam distrust supermarkets guarantees, preferring to source food (often organic) directly from trusted farmers [START_REF] Downs | The interface between consumers and their food environment in Myanmar: an exploratory mixed-methods study[END_REF][START_REF] Ha | Food risk in consumers' eye and their consumption responses: evidence from Hanoi survey[END_REF][START_REF] Kendall | Chinese consumer's attitudes, perceptions and behavioural responses towards food fraud[END_REF]Wertheim-Heck and Spaargaren, 2015). These middle-class consumers order vegetables and animal sourced items online from rural areas to be delivered to their urban homes. This trend seems to be increasing among consumers in China due to the COVID-19 pandemic, opening further challenges to reassuring consumers and ensuring food safety supply chains [START_REF] Zhang | Dietary behaviors in the post-lockdown period and its effects on dietary diversity: the second stage of a nutrition survey in a longitudinal Chinese study in the COVID-19 era[END_REF]. However, low-income consumers face a different set of challenges, with supermarkets and online fruit or vegetable orders representing unaffordable and inaccessible alternatives. The 'supermarketisation' of urban areas and cities is often viewed as a way to guarantee a regulated food system. However, traditional markets, such as wet markets, often represent an important and preferred food outlet in LMICs [START_REF] Béné | Policy framing and crisis narratives around food safety in Vietnam[END_REF][START_REF] Chuvileva | From wet markets to Wal-Marts: tracing alimentary xenophobia in the time of COVID-19[END_REF][START_REF] Figuié | Market appeal in an emerging economy: supermarkets and poor consumers in Vietnam[END_REF]. Therefore, the needs and preferences of low-income consumers is important to avoid the negative effects on purchase, consumption and livelihoods. Especially as a lack of alternatives can lead poor consumers to buy what is available, despite FS concerns [START_REF] Liu | Chinese consumers food purchasing behaviors and awareness of food safety[END_REF].

With the nutrition transition well underway in urban LMIC settings [START_REF] Bailey | Food choice drivers in the context of the nutrition transition in Delhi, India[END_REF][START_REF] Baker | Ultraprocessed foods and the nutrition transition: global, regional and national trends, food systems transformations and political economy drivers[END_REF][START_REF] Rousham | Dietary behaviours in the context of nutrition transition: a systematic review and meta-analyses in two African countries[END_REF], the fear of poor hygiene, environmental sanitation, food contamination and adulteration of food are major concerns [START_REF] Pradeilles | Urban physical food environments drive dietary behaviours in Ghana and Kenya: a photovoice study[END_REF] and could affect the already low consumption of fruit and vegetables in some LMICs [START_REF] Bailey | Food choice drivers in the context of the nutrition transition in Delhi, India[END_REF][START_REF] Rousham | Dietary behaviours in the context of nutrition transition: a systematic review and meta-analyses in two African countries[END_REF]. While healthy diets in LMICs are unaffordable to many (SOFI, 2020), the avoidance of fresh FFV due to FS concerns could potentially increase the already high consumption of ultra-processed foods and beverages, further disrupting progress towards current nutritional and sustainable development goals (SDGs) in LMICs [START_REF] Baker | Ultraprocessed foods and the nutrition transition: global, regional and national trends, food systems transformations and political economy drivers[END_REF][START_REF] Unicef | Levels and Trends in Child Malnutrition[END_REF].

Recommendations for future research

Several recommendations for research emerge from this analysis. These included increasing sample sizes to make findings more representative and generalizable [START_REF] Behrens | Consumer purchase habits and views on food safety: a Brazilian study[END_REF][START_REF] Cheng | Consumers' behaviors and concerns on fresh vegetable purchase and safety in Beijing urban areas, China[END_REF][START_REF] Ergönül | Consumer awareness and perception to food safety: a consumer analysis[END_REF][START_REF] Figuié | Sustainable development of peri-urban agriculture in South-East Asia project. Vegetable consumption behaviour in Vietnam[END_REF][START_REF] Kendall | Chinese consumer's attitudes, perceptions and behavioural responses towards food fraud[END_REF][START_REF] Maitiniyazi | Understanding Chinese consumers' safety perceptions of dairy products: a qualitative study[END_REF][START_REF] Pham | If I want safe food I have to grow it myself': patterns and motivations of urban agriculture in a small city in Vietnam's northern borderlands[END_REF][START_REF] Stanton | Changing consumer preferences in emerging markets: food market challenges in Central Mexico[END_REF][START_REF] Trubswasser | Assessing factors influencing adolescents' dietary behaviours in urban Ethiopia using participatory photography[END_REF][START_REF] Veeck | Influences on food choices of urban Chinese teenagers[END_REF][START_REF] Wertheim-Heck | Food safety and nutrition for lowincome urbanites: exploring a social justice dilemma in consumption policy[END_REF]. Matching consumers' perceived safety risks with microbial or (bio)chemical tests to distinguish hazards from actual risks is also recommended [START_REF] Figuié | Sustainable development of peri-urban agriculture in South-East Asia project. Vegetable consumption behaviour in Vietnam[END_REF][START_REF] Wertheim-Heck | Food safety and nutrition for lowincome urbanites: exploring a social justice dilemma in consumption policy[END_REF]. This finding is supported by a study that showed that only 2% of the meat in Ibadan, Nigeria and 0% of tested milk samples in Assam state (India) met recommended standards [START_REF] Grace | Safe Food, Fair Food: participatory risk analysis for improving the safety of informally produced and marketed food in sub-Saharan Africa[END_REF]. Further investigation of retail outlets and their typologies was also recommended in Vietnam, based on the need for participatory involvement (Wertheim-Heck et al., 2015, 2019). Furthermore, direct measures of the effects of food safety on consumer confidence, perceived risk and purchase intention [START_REF] Fatimah | Foodservice hygiene factors-the consumer perspective[END_REF] are needed. We also found that it was difficult to directly link influencing factors with outcomes, since many studies failed to fully assess consumer behaviors and even fewer studies collected data on actual diets. To identify opportunities for targeted and tailored future food safety interventions, data on individual behaviors and practices are needed.

Participatory inclusive risk analysis with good risk communication [START_REF] Grace | Safe Food, Fair Food: participatory risk analysis for improving the safety of informally produced and marketed food in sub-Saharan Africa[END_REF] on lived experiences [START_REF] Neve | Understanding lived experience of food environments to inform policy: an overview of research methods[END_REF] were also proposed by several studies in Vietnam. These studies discuss the need to listen to consumers' concerns and preferences to find retail outlets, perhaps 'hybrid structures' [START_REF] Wertheim-Heck | Constrained consumer practices and food safety concerns in Hanoi[END_REF], that suit consumers best [START_REF] Figuié | Sustainable development of peri-urban agriculture in South-East Asia project. Vegetable consumption behaviour in Vietnam[END_REF][START_REF] Figuié | Market appeal in an emerging economy: supermarkets and poor consumers in Vietnam[END_REF]Wertheim-Heck et al., 2015, 2019;Wertheim-Heck and Spaargaren, 2015). Participatory approaches can guide researchers and policy makers to use a food systems approach to address all forms of malnutrition and food safety comprehensively. It was surprising that only four studies discussed the need to combine food safety into policies and practices that focus on nutrition, chronic disease and overweight and obesity [START_REF] Bastami | Factors behind healthy snack consumption at school among high-school students: a qualitative study[END_REF][START_REF] Blum | In-depth assessment of snacking behaviour in unmarried adolescent girls 16-19 years of age living in urban centres of Java, Indonesia[END_REF][START_REF] Trubswasser | Assessing factors influencing adolescents' dietary behaviours in urban Ethiopia using participatory photography[END_REF][START_REF] Wertheim-Heck | Food safety and nutrition for lowincome urbanites: exploring a social justice dilemma in consumption policy[END_REF]. Overlooking this focus in food safety research on consumer behavior should be particularly salient for increasing overweight/obesity polices and programming in LMICs [START_REF] Béné | Policy framing and crisis narratives around food safety in Vietnam[END_REF][START_REF] Shekar | Obesity: Health and Economic Consequences of an Impending Global Challenge[END_REF].

Recommendations for policy action

The review allows us to identify a series of policy recommendations. Seven studies evoked the need to increase food safety education initiatives targeting the general population or specifically food vendors [START_REF] Adam | Students' food safety concerns and choice of eating place in Ghana[END_REF][START_REF] Behrens | Consumer purchase habits and views on food safety: a Brazilian study[END_REF][START_REF] Correa | Perceptions of healthy eating amongst Indian adolescents in India and Canada[END_REF][START_REF] Knight | Household food safety awareness of selected urban consumers in Jamaica[END_REF][START_REF] Liu | Chinese consumers food purchasing behaviors and awareness of food safety[END_REF][START_REF] Rheinlander | Keeping up appearances: perceptions of street food safety in urban Kumasi, Ghana[END_REF][START_REF] Sanlier | Evaluation of food purchasing behaviour of consumers from supermarkets[END_REF]. Improved regulations and/or the management or enforcement of current regulations was also frequently cited as a crucial area for change [START_REF] Ha | Food risk in consumers' eye and their consumption responses: evidence from Hanoi survey[END_REF][START_REF] Kendall | Chinese consumer's attitudes, perceptions and behavioural responses towards food fraud[END_REF][START_REF] Nguyen | Customers' knowledge, attitude, and practices towards food hygiene and safety standards of handlers in food facilities in Hanoi, Vietnam[END_REF][START_REF] Sanlier | Evaluation of food purchasing behaviour of consumers from supermarkets[END_REF][START_REF] Trubswasser | Assessing factors influencing adolescents' dietary behaviours in urban Ethiopia using participatory photography[END_REF][START_REF] Valente | Profile of food truck consumers and their opinion about food safety[END_REF][START_REF] Veeck | Influences on food choices of urban Chinese teenagers[END_REF]. Certification, labelling and accreditation schemes were also suggested as a way to improve the quality of food [START_REF] Downs | The interface between consumers and their food environment in Myanmar: an exploratory mixed-methods study[END_REF][START_REF] Lagerkvist | How consumer confidence in food safety practices along the food supply chain determines food handling practices: evidence from Ghana[END_REF][START_REF] Maitiniyazi | Understanding Chinese consumers' safety perceptions of dairy products: a qualitative study[END_REF]. These recommendations have been further explored in a review in West Africa (Keraita and Drechsel, 2015), which concluded that regulatory measures, such as certification are not the most effective measure to improve food safety due to limited or overburdened institutional capacities [START_REF] Grace | Food safety in low and middle income countries[END_REF]Wertheim-Heck et al., 2015;[START_REF] Who | Food Safety Fact Sheet[END_REF]. Improving and upgrading food safety in LMICs is important as most of the food system relies on the informal sector, which can have a significant impact on human and economic value.

Conclusion

Our findings confirm that food safety concerns influence consumer behaviors and diets. As these concerns are widespread in LMICs, they should be taken into account in food safety regulations. However, a focus on food safety and supermarket-only strategies, to reduce consumer unease about FS could distort the longer-term policy agenda away from other important issues. These trade-offs should be taken into consideration to create real solutions that ensure availability, nutritional adequacy and the safety of the food system, especially as the COVID-19 pandemic places a greater strain on food systems and dietary practices [START_REF] Chuvileva | From wet markets to Wal-Marts: tracing alimentary xenophobia in the time of COVID-19[END_REF][START_REF] Fanzo | Cooperate to prevent food-system failure[END_REF]. Taking the opportunity to combine these issues within the broader food system agenda, including overweight and obesity prevention or affordability of healthy foods is important. Failing to understand consumers' perceptions and behavior around these FS issues and missing the opportunity to, could further exacerbate the current unsustainability of food systems as we observe them in LMICs.

Fig. 2 .

 2 Fig. 2. PRISMA diagram showing the systematic screening process.

  L = low-income; LM = lower-middle income; UM = upper-middle income; FS = food safety; F = female; M = male; DB = dietary behaviour; DB1 = acquisition/purchase at different outlets/vendors/different neighbourhoods (e.g. shifting purchase from small, informal to larger, formal outlet); DB2 = changes in frequency eating out/vendor/venue; DB3 = food preparation (and storage); DB4 = avoiding unsafe food/eating

Fig. 3 .

 3 Fig. 3. Here Map showing density of food safety research-*Footnote Nb = number of studies conducted in each country.

Table 1

 1 Key characteristics of all included studies (n = 46). how safe food is when I buy it by myself. When I go out with my grandparents, they take care of this and ask me to figure out whether something is within the expiration date[…] If I don't pay attention to expiration date, I may get sick. If I do this, I will at least have some protection" [Male, 15 years, China][START_REF] Veeck | Influences on food choices of urban Chinese teenagers[END_REF].

	Author	Year	Country	Income	Population	Number of	Gender	FS exposure/socio-ecological factor		DB outcome
				quartile		participants		Macro	Physical	Social	Household	Individual	DB1	DB2	DB3	DB4
	Mixed Methods
	April-Lalonde et al.	2020	Ecuador	UM	Adults	2929	M & F	✔	✔				✔
	Bailey et al	2018	India	LM	Adults	38	F		✔				✔	✔		✔
	Downs et al.	2018	Myanmar	LM	Adults	94	M & F					✔	✔			✔
	Figuié	2003	Vietnam	LM	Not reported	210	M & F	✔	✔	✔		✔	✔		✔
	Figuié & Moustier	2009	Vietnam	LM	Adolescents &	110	M & F		✔				✔		✔
					adults
	Ha et al.	2020	Vietnam	LM	Adults	268	M & F		✔	✔	✔		✔	✔
	Lachat et al.	2011	Vietnam	LM	Adolescents	194	M & F					✔		✔
	Ramaroson Rakotosamimanana	2014	Madagascar	L	Adults	1072	M & F		✔			✔	✔		✔	✔
	et al.
	Wertheim-Heck et al.	2015	Vietnam	LM	Not reported	2206	M & F		✔	✔	✔		✔		✔	✔
	Wertheim-Heck et al.	2019	Vietnam	LM	Not reported	400	F		✔				✔
	Qualitative
	Adam et al.	2014	Ghana	LM	Adults	1106	M & F		✔					✔
	Bastami et al.	2019	Iran	UM	Adolescents &	42	M & F		✔							✔
					adults
	Behrens et al.	2010	Brazil	UM	Adults	30	M & F		✔	✔			✔		✔	✔
	Blum et al.	2019	Indonesia	UM	Not reported	Not reported	F		✔		✔					✔
	Boatemaa et al.	2018	Ghana	LM	Adolescents &	30	M & F							✔	✔
					adults
	Correa et al.	2017	India and	LM	Adolescents	73	M & F					✔		✔
			Canada
	Hunter-Adams et al.	2019	South Africa	UM	Adults	78	M & F		✔							✔
	Kendall et al.	2018	China	UM	Adults	42	M & F	✔	✔	✔	✔	✔	✔	✔	✔	✔
	Li et al.	2018	China	UM	Adults	45	M & F		✔			✔		✔	✔
	Maitiniyazi & Canavari	2021	China	UM	Adults	61	M & F		✔			✔	✔
	Nago et al.	2012	Benin	LM	Adolescents	153	M & F		✔	✔		✔		✔	✔	✔
	Pahlm et al.	2013	Nepal	LM	Adolescents	24	M & F					✔			✔
	Pham & Turner	2020	Vietnam	LM	Adults	43	M & F	✔	✔		✔	✔	✔
	Rheinlander et al.	2008	Ghana	LM	Adolescents &	67	M & F		✔	✔		✔		✔
					adults
	Sondari et al.	2019	Indonesia	UM	Adolescents	19	F					✔		✔
	Stanton	2019	Mexico	UM	Adults	20	M & F	✔	✔	✔	✔	✔	✔			✔
	Trübswasser et al.	2020	Ethiopia	L	Adolescents	26	M & F		✔		✔	✔		✔	✔	✔
	Veeck et al.	2014	China	UM	Adolescents	36	M & F		✔			✔	✔	✔
	Verstraeten et al.	2014	Ecuador	UM	Adolescents	144	M & F		✔							✔
	Wertheim-Heck et al.	2014	Vietnam	LM	Not reported	176	M & F	✔	✔	✔			✔		✔
	Wertheim-Heck	015	Vietnam	LM	Adults	66	M & F		✔	✔	✔	✔	✔	✔
	Yiga et al.	2020	Uganda	L	Adults	81	F		✔						✔	✔
	Quantitative
	Cheng et al.	2016	China	UM	Not reported	590	M & F		✔		✔	✔	✔			✔
	Ergönul	2013	Turkey	UM	Adolescents &	600	M & F	✔	✔	✔		✔	✔			✔
					adults
	Fatimah et al.	2011	Malaysia	UM	Adults	244	M & F		✔					✔
	Hiamey & Hiamey	2018	Ghana	LM	Not reported	315	M & F		✔			✔		✔
	Hu et al.	2017	China	UM	Not reported	4236	M & F		✔			✔		✔
	Knight et al.	2003	Jamaica	UM	Adults	110	M &F		✔		✔					✔
	Lagerkvist et al.	2018	Ghana	LM	Adolescents &	332	M & F	✔	✔						✔
					adults
	Liu et al.	2014	China	UM	Adolescents &	1000	M & F		✔			✔		✔
					adults
														(continued on next page)

tell

Table 1

 1 (continued )

Acknowledgments/Authors' contributions: MH, NB and RP defined the scope of the review. UT conducted the scoping searches to inform the review and protocol. All authors participated in the protocol writing. JL and UT conducted the search, screening, data extraction and quality assessment. JL conducted the analysis. MH and RP advised on the search, data extraction and analysis format. ALP/EL/ET served as reviewers for verifying quality appraisal, full text screening and/or data extraction. JL, UT, MH, RP wrote the first draft of the paper. All authors read and approved the final manuscript.

Funding

This review was supported by funding from CGIAR Research Program on Agriculture for Nutrition and Health (A4NH).

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

Supplementary data to this article can be found online at https://doi. org/10.1016/j.gfs.2021.100606.