Introduction

There has been rise in the gastrointestinal diseases due to lifestyle changes among the people. A sudden shift to sedentary behaviour and reduced physical activity disturbs the hormonal balance that effects beneficial gut microbial composition. This impacts the overall health of the individual1,2. Also, the administration of antibiotics especially in children leads to the damage of gut microbes3. This has made the population to focus on the intake of gut friendly natural food products, beneficial for all age groups like probiotics products.

Probiotics are live micro-organisms which when administered in adequate amounts, provide health benefits. These are commonly known as gut-friendly bacteria or yeast4,5,6) like the species of Lactobacillus, Bifidobacterium7 and Saccharomyces6. They are referred to as the bioactive components of functional foods that stimulate metabolic activities beyond basic nutrition. In the present industrialized world, functional foods have become a part of an everyday diet and are demonstrated to offer potential health benefits beyond the widely accepted nutritional effects. It has been suggested that approximately 109 CFU per day of probiotics are necessary to elicit health effects. Based on the daily consumption of 100 g or ml of probiotic food, it has been suggested that a product should contain at least 107 cells per g or ml of a food, a level that was also recommended in Japan8.

The probiotic foods beneficially affect the host by improving survival and implantation of live microbes in the gastrointestinal tract. This selectively stimulates the growth or activates the catabolism of one or a limited number of health-promoting bacteria in the intestinal tract. There are different probiotic species that help in maintaining the health of an individual. Some of them are mentioned in Table 19.

Table 1 List of some probiotics and their effects on health.
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Probiotics are normally added to foods as a part of the fermentation process. The emphasis for prolonged survival of probiotics in the food matrix has resulted in the alteration in the functionality and efficacy of the food product. To exert health benefits, probiotic bacteria must remain viable in the food carriers and survive the harsh conditions of GI tract, with a minimum count of 106 CFU/g. The most popular food delivery systems for probiotics have been fermented milk and yoghurt. A growing public awareness regarding diet-related health issues has increased the demand for probiotic foods9.

With the growing demand, it is important that people should also know about the constituents or important components in a particular food that is responsible for making a food functional. Not only consumption, but also emphasis should be given to certain important characteristics in a food. In one of the studies on probiotics, it is reported that although people are aware about probiotics and their products but still, they lack knowledge on their application, proper dosage and frequency of usage10. This indicates that there is limited research about the awareness of probiotics among the Indian population regarding proper consumption and applications of probiotic products11.

The knowledge, attitude and practice (KAP) survey is a diagnostic research tool that creates a groups’ beliefs, actions, contents towards a valid scientific data on a specific subject especially related to health. Accordingly, knowledge influences attitude that significantly results in action12,13,14.

In this paper, a survey has been carried out among the participants in India based on knowledge, attitude and practice of the consumers related to probiotics and their products. The objectives of the research include:

  • To statistically analyse the awareness of the respondents for probiotics and their products through knowledge, attitude and practice.

  • To initiate certain steps and measures for spreading the concept about probiotics and their products.

Methodology

Study design and participants

A cross-sectional study was conducted through an online survey. A structured questionnaire was circulated via emails by sharing the google form link (https://forms.gle/oV3iFLiH68fYRNX69) randomly to the people in all the states and union territories of the country in the month from July 2023 to September, 2023. The inclusion criteria involved volunteers in the age group below 15 to above 50 years, both males and females. The sample size was determined based on the guideline of having 5–10 times the number of questionnaire items15.

Structured questionnaire

A structured questionnaire was created using Google forms. The reliability and validity of the questionnaire was tested by randomly sampling 20 individuals, through Cronbach’s (α) value.

The final questionnaire was designed consisting of four major sections: in “Introduction” section included 06 questions on general features of the respondent—age; gender; state/U.T. of residence; occupation and field of specialization. In “Methodology” section consisted of 05 questions regarding the knowledge aspect of the respondent related to probiotics—whether known or unknown; source of information; the need for the consumption; their importance and foods containing probiotics. The attitude of the respondent towards probiotics was covered in “Results” section. This included 06 questions regarding benefits provided by probiotics; affordability of the products by all income families; marketing strategy to sell products; claims made on packaging regarding probiotics; preference to consume if available and consumption on recommendation. In “Discussion” section of the questionnaire consisted of 05 questions based on respondent practices like consumption of any probiotic product on regular basis; knowledge about the products available; frequency of product consumption and preparation of any product at home. The format of the questions was mostly as “yes/no” or choosing and appropriate option from the given choices.

Ethical considerations

All the methods were carried out in accordance with relevant guidelines and regulations by School of Science, Gandhi Institute of Technology and Management Deemed to be University, Hyderabad. The questionnaire was approved by GITAM Ethical committee, Visakhapatnam, India. For filling the questionnaire, the informed consent was obtained from all the subjects and their legal guardian(s).

Data collection and quality control

The data from the individual participants was submitted within the given timeline from July to September 2023 through google form link as mentioned above. The data quality was ensured by restricting only 1 response per IP address. All the questions were made mandatory. The questionnaire completed in less than 10 min and with any logical error was considered invalid.

Statistical analysis

Statistical analysis was conducted using statistical package for social sciences (SPSS) v31. The comparisons between two groups were made using independent samples F-test and T-test. In “Introduction” section, responses for age and gender were statistically analysed using the F-Test: Two sample for variance was to know whether these factors are dependent on one-another and affect the awareness. In “Methodology” and “Discussion” sections, the responses were statistically analysed using T-test: two-sample assuming equal variances to determine any statistical difference.

The comparisons among three and more groups were done using analysis of variance (ANOVA). The number of respondents was represented as N.

Univariate variables (P ≤ 0.05) were analysed using regression. In “Results” section, the impact of the responses on each factor was statistically analysed using Regression.

To assess the correlations between the scores of knowledge, attitude and practice, Pearson correlation was applied. The values between − 1 and 1: negative correlation, the values between − 1 and 0: 0 correlation, values between 0 and 1: positive correlation, the values close to 1 and 1: greater association between variables was considered for analysis. The P value (P ≤ 0.05) was considered statistically significant for the study.

Results

Number of responses and validity of questionnaire

The questionnaire contained 22 items, so based on this, the sample size was taken to be 300 (as it should be between 220 and 300). The responses from online survey across the country received was 317. The responses considered were 305 (excluding 10 responses that were completed before 10 min time and 2 responses with logical errors).

The random sampling of 20 individuals for validating structured questionnaire, provided with Cronbach’s (α) value of 0.85 that suggests good internal consistency.

Section 1: general features of respondents

The responses from online survey across the country received was 317. The percentage of responses including the northern part (north east and north west) of country—50.1% (Assam, Bihar, Chandigarh, Delhi, Haryana, Himachal Pradesh, Jammu & Kashmir, Jharkhand, Odisha, Punjab, Uttarakhand, Uttar Pradesh, West Bengal; central India- 3% (Chhattisgarh, Madhya Pradesh, Gujarat, Daman and Diu) % and southern part (including UTs)—47.5% (Andhra Pradesh, Andaman and Nicobar, Goa, Karnataka, Kerala, Lakshadweep, Maharashtra, Pondicherry, Tamil Nadu, Telangana). Out of the states covered, Telangana showed maximum response rate; Haryana being the second highest followed by Himachal Pradesh (Fig. 1, Table 6). The knowledge score was found to be highest for Haryana (73.1%) and Uttarakhand (72.5%); attitude score—Delhi NCR (76%) and Karnataka (68.3%) whereas the practice score for the state Uttarakhand (81.2%) was found to be highest, followed by Haryana (61%) (Table 6). The states with N = 1% was not considered for the score comparison.

Fig. 1
Fig. 1The alternative text for this image may have been generated using AI.
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Responses received from different parts of the country.

Considering the demographic data for gender and age group, the responses received from females were 196 (64.3%) and males—109 (35.7%) which included the age group between below 15 years to above 50 years contributing to the maximum responses from females. This age group included entrepreneurs/self-employed—8 (2.6%), home-makers—22 (7.2%), retired personnels—5 (1.6%), salaried professionals—74 (24.2%) and students—87 (28.5%). The students from sciences include—80 (92%) and non-sciences—7 (8%) while the salaried professionals were associated with agriculture—2 (2.7%); biological and life sciences—29 (39%); food sciences—16 (22%); others (accountancy, banking, administration, IT/computer science, finance and trading, data science, aviation, physics, management, education, software engineer, pilot)—50 (67.5%). Overall, the ratio of salaried professionals for life sciences including agriculture and food science to non-biological fields obtained was 0.94. The statistical analysis by F-test showed that the variance of both factors—age and gender are equal, df − 1 and do not affect the awareness (Table 2). The data for the general features is shown in Table 6.

Table 2 Statistical analysis using F-test: two-sample for variance.
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Section 2: knowledge

According to the responses received, 90% of them were known about the probiotics and 10% of the respondents did not know (Table 5). For 45% of them, the source of information was the internet; 30% of them were not sure and rest of them knew from medical practitioners—10%; friends—10%, market and family—10%. Regarding knowledge about the importance of probiotics, 80% respondents were aware including 72% consuming the products as they improved health and some of them consumed on recommendation of a medical practitioner or on suggestion of their friends; but rest 20% of the respondents were not aware about the importance of probiotics. For the food products which contained probiotics, the maximum responses were for yogurt and curd, followed by kefir. 10% of them also responded for milk and rest as none. The statistical analysis using T-test showed that the P value is below 0.05 (P ≤ 0.05) and the hypothesized mean difference is 0, which indicates that no significant difference is observed between the two parameters (Table 3).

Table 3 Statistical analysis using T-test: two-sample assuming equal variance.
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Section 3: attitude

Regarding all the benefits that are offered by probiotics, only 58% of the participants responded correctly while some gave only one or two correct answers. 42% claimed that the products are affordable for all income families. The percentage of people who are aware about the importance of probiotic products agree that the products have beneficial health effects and not just a marketing strategy to sell the products. When probiotic products are available, 87.2% respondents would like to consume these foods, especially when recommended by nutritionists or medical practitioners. For the claims made on food packaging regarding probiotics, only 26% respondents agree while others are not sure or have no idea. The statistical analysis using Linear Regression showed the residual (observed value) coincides with the predicted value (Fig. 2; Table 4) and the P value obtained for predicated value is 0.01 which shows there is no significant difference. Also, there is a shift in the predicted value of univariate variable from − 2 to 0.61; R2 = 0.54 that shows no linear relationship between agreed and disagreed respondents. R2adg = 39% indicates involvement of other factors like non-participation of all respondents to the questions and some respondents being unsure to the answers (Table 5).

Fig. 2
Fig. 2The alternative text for this image may have been generated using AI.
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Line fit plot by regression indicating no significant difference with disagree of respondents.

Table 4 Residual output by linear regression analysis.
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Table 5 Linear regression model summary.
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Section 4: practice

Out of 305 respondents, 70% of them have consumed these products where 35% of them have occasionally: 23% every day and 20% once or twice a week (Fig. 3). The statistical analysis using T-test showed that the P value is below 0.05 (P ≤ 0.05) and the hypothesized mean difference is 0, which indicates that no significant difference is observed between the two parameters.

Fig. 3
Fig. 3The alternative text for this image may have been generated using AI.
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Consumption of probiotic foods.

Maximum of them prepare these probiotic foods at home. But few of them also consider fermented products as probiotic products as they are unaware about the microbiological difference between these products. The awareness about the probiotic products existing in the market is shown in Fig. 4.

Fig. 4
Fig. 4The alternative text for this image may have been generated using AI.
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Awareness of respondents towards products existing in market.

Knowledge, attitude, practice for different parameters

The mean knowledge, attitude and practice scores were 16, 23 and 8 respectively as determined by the scores from the responses. The knowledge, attitude and practice scores varied from respondents for age (P = 0.000181), gender (P = 0.000126), states (P = 4.19616433247292E−13), field of specialization (P = 0.000148) and occupation (P = 0.000794) (Table 6).

Table 6 General features indicating KAP scores and statistical analysis.
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Discussion

When age is a factor, there is a positive correlation (r) between knowledge and attitude which signifies that with age the attitude about probiotic products increases through knowledge but there might be a positive correlation between attitude and practice. The people who are aware about the products may or may not apply them in their daily life. Gender: There is a positive correlation (r) between attitude and practice which signifies that the applicability and consumption of probiotic products increase with the attitude that where gender plays a very important role. In this study, it has been effective for females for awareness about probiotic products. Among different states, a positive correlation is found between attitude and practice that signifies overall awareness for the state Uttarakhand in India. For field of specialization and occupation, a positive correlation is found among knowledge, attitude and practice. This signifies that people who belong to science background, especially with biological or life sciences have more awareness regarding probiotics in India.

The results are comparable to that of a study conducted from Saudi Arab, where it is reported that the knowledge influences the approach and attitude of the people towards the probiotic products related to prevention of a disease16. The studies conducted in Delhi region regarding awareness of probiotics, it was found that younger participants aged 30 years and below has shown high awareness among public17. In one of the studies on probiotics conducted in Chennai, it is reported that although people are aware about probiotics and their products but still, they lack knowledge on their application, proper dosage and frequency of usage10. Also, survey conducted in Oman showed that the students who belonged to medical fields did not have much knowledge about the probiotics18. The age and gender among the Indian participants created no difference in the awareness regarding probiotics and related products19. The study conducted on Indian adults stated that almost 90% of the respondents from online survey knew the immune enhancing benefits of probiotics11. It was mentioned that 40% of the individuals in Haryana knew dahi and yogurt to be sources of probiotics. Regarding source of information of probiotics enough literature is not available20. Regarding intake by nutritionists or physicians, it was a minor factor while affordability could be one of the major factors in influencing the consumption or awareness of probiotic products6,19,20,21. A study suggested that the health value of probiotics; their existing benefits and lack of side-effects were the factors motivating the consumption of these products by public in India20.

Limitations in the study: Due to a limited number of sample size—300 covering all states in India, the results are generated as per the data obtained. The states with N = 1% was not considered for the score comparison. The knowledge, attitude and practice about the probiotic products from participants of various states in India is represented based on scores obtained and statistical analysis of the responses. Additional research is required to generalize the possible outcomes. For further research, self-questionnaire via paper survey covering more questions under supervision can reduce the possibility of response biasness and data errors.

Conclusion

The probiotic foods beneficially affect the host by improving survival and implantation of live microbes in the gastrointestinal tract22. This helps in maintaining the gut health of an individual23,24,25. Through this study, awareness, importance, and consumption among the participants in India is analysed related to probiotic products. Regarding the general features, it was found that participants from Uttarakhand were found to be aware and Haryana being the second highest. The statistical analysis by F-test showed that the variance of both factors—age and gender as equal, df − 1 and do not affect the awareness. The participants from Delhi and Karnataka showed a positive approach towards the market value about the probiotic products in future. The participants in India were aware about the benefits and applicability but somehow lack knowledge in the right amount of consumption of these foods from nutritional aspects. Some training sessions, more advertisements or contests can be arranged for people at household level especially regarding right consumption. The focus on price of these products should also be considered as an important perspective towards more consumption by Indian population.