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Effect of Behavior Change Intervention on Complementary Food Contamination in Rural Bangladesh: A Cluster-Randomized Controlled Trial
Tarique Md. Nurul Huda
t.huda@qu.edu.sa
Tarique Md. Nurul Huda
Department of Public Health, College of Applied Medical Sciences, Qassim University, Buraydah, Saudi Arabia;
Environmental Health and WASH, Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh;
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Environmental Health and WASH, Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh;
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Anna A. Müller-Hauser
Anna A. Müller-Hauser
Research Department 2, Potsdam Institute for Climate Impact Research (PIK), Member of the Leibniz Association, Potsdam, Germany;
Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Public Health, Berlin, Germany;
Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany;
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Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Public Health, Berlin, Germany;
Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany;
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Shafinaz Sobhan
Shafinaz Sobhan
Research Department 2, Potsdam Institute for Climate Impact Research (PIK), Member of the Leibniz Association, Potsdam, Germany;
Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Public Health, Berlin, Germany;
Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany;
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Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Public Health, Berlin, Germany;
Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany;
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Shaheen Hossain
Shaheen Hossain
Environmental Health and WASH, Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh;
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Jesmin Sultana
Jesmin Sultana
Environmental Health and WASH, Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh;
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Mahbubur Rahman
Mahbubur Rahman
Environmental Health and WASH, Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh;
Global Health and Migration Unit, Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden;
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Global Health and Migration Unit, Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden;
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Mohammad Aminul Islam
Mohammad Aminul Islam
Paul G. Allen School for Global Health, Washington State University, Pullman, Washington;
Food Microbiology Laboratory, Laboratory Sciences and Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh;
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Food Microbiology Laboratory, Laboratory Sciences and Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh;
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Om Prasad Gautam
Om Prasad Gautam
WaterAid United Kingdom, London, United Kingdom;
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Amanda S. Wendt
Amanda S. Wendt
Research Department 2, Potsdam Institute for Climate Impact Research (PIK), Member of the Leibniz Association, Potsdam, Germany;
Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany;
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Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany;
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Jillian L. Waid
Jillian L. Waid
Research Department 2, Potsdam Institute for Climate Impact Research (PIK), Member of the Leibniz Association, Potsdam, Germany;
Helen Keller International, Bangladesh Country Office, Research, Learning and Evaluation, Dhaka, Bangladesh
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Helen Keller International, Bangladesh Country Office, Research, Learning and Evaluation, Dhaka, Bangladesh
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Sabine Gabrysch
Sabine Gabrysch
Research Department 2, Potsdam Institute for Climate Impact Research (PIK), Member of the Leibniz Association, Potsdam, Germany;
Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Public Health, Berlin, Germany;
Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany;
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Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Public Health, Berlin, Germany;
Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany;
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ABSTRACT.
Children in low-resource settings often consume microbially contaminated food, risking their health. We evaluated the impact of a food hygiene intervention on complementary food contamination in Bangladesh. A 3-year homestead food production intervention was complemented by an 8-month behavior change module to improve household food hygiene practices and evaluated in a cluster-randomized controlled trial, including a dedicated study measuring outcomes along the hygiene pathway to intestinal health. We used multilevel regression to assess the intervention’s impact on microbial food contamination as well as food hygiene knowledge (n = 518) and reported practices (n = 531) among mothers of children 6–23 months of age. Complementary food samples were collected from 342 households with children 6–18 months of age and tested for Escherichia coli. Overall, 46% of food samples were contaminated with E. coli (43% intervention, 51% control), and there was no evidence that the intervention reduced food contamination (odds ratio: 0.65, 95% CI: 0.35–1.21). A higher proportion of intervention mothers could name all key food hygiene practices (23% intervention versus 1% control), had access to a basic handwashing station near the kitchen (24% versus 14%), reported washing hands before food preparation and child feeding (21% versus 8%), reported washing and storing feeding utensils safely (61% versus 49%), and reported preparing food fresh or reheating stored food (88% versus 79%) compared with control mothers. The intervention thus improved knowledge and reported food hygiene practices among mothers, but this improvement did not result in a substantial reduction of complementary food contamination.
- Supplemental Materials (PDF 451.56 KB)
Author Notes
Financial support: The Food and Agricultural Approaches to Reducing Malnutrition trial was primarily funded by the
Disclosures: This trial is registered at ClinicalTrials.gov (#NCT02505711). The Food and Agricultural Approaches to Reducing Malnutrition trial protocol was positively reviewed by the ethics committees of the Medical Faculty at Heidelberg University in Germany (reference S-121/2014) and by the James P. Grant School of Public Health, BRAC University in Bangladesh (reference 37A). The Food Hygiene to Reduce Environmental Enteric Dysfunction study protocol was positively reviewed by the Medical Faculty at Heidelberg University (reference S-606/2017) and by the International Centre for Diarrhoeal Disease Research, Bangladesh (reference PR-17126). All participants provided informed written consent by signature or thumbprint.
Current contact information: Tarique Md. Nurul Huda, Department of Public Health, College of Applied Medical Sciences, Qassim University, Buraydah, Saudi Arabia, E-mail: t.huda@qu.edu.sa. Anna A. Müller-Hauser, Shafinaz Sobhan, Amanda S. Wendt, Jillian L. Waid and Sabine Gabrysch, Potsdam Institute for Climate Impact Research, Potsdam, Germany, E-mails: anna.mueller@pik-potsdam.de, shafinaz.sobhan@pik-potsdam.de, amanda.wendt@pik-potsdam.de, jillian.waid@pik-potsdam.de, and sabine.gabrysch@pik-potsdam.de. Shaheen Hossain, Jesmin Sultana, and Mahbubur Rahman, Environmental Health and WASH, Health System and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh, E-mails: saheenhossen@icddrb.org, jesmin.sultana@icddrb.org, and mahbubr@icddrb.org. Mohammad Aminul Islam, Paul G. Allen School for Global Animal Health, Washington State University, Pullman, WA, E-mail: amin.islam@wsu.edu. Om Prasad Gautam, WaterAid United Kingdom, London, United Kingdom, E-mail: OmPrasadGautam@wateraid.org.
ProCite
RefWorks
Reference Manager
BibTeX
Zotero
EndNote
-
1.
GBD Diarrhoeal Diseases Collaborators, 2017. Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: A systematic analysis for the Global Burden of Disease Study 2015. Lancet Infect Dis 17: 909–948.
-
2.
GBD 2019 Diseases and Injuries Collaborators, 2020. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet 396: 1204–1222.
-
3.
Pires SM, Fischer-Walker CL, Lanata CF, Devleesschauwer B, Hall AJ, Kirk MD, Duarte AS, Black RE, Angulo FJ, 2015. Aetiology-specific estimates of the global and regional incidence and mortality of diarrhoeal diseases commonly transmitted through food. PLoS One 10: e0142927.
-
4.
WHO Food Safety. Available at: https://www.who.int/en/news-room/fact-sheets/detail/food-safety. Accessed May 12, 2020.
-
5.
George CM et al., 2015. Fecal markers of environmental enteropathy are associated with animal exposure and caregiver hygiene in Bangladesh. Am J Trop Med Hyg 93: 269–275.
-
6.
Humphrey JH, 2009. Child undernutrition, tropical enteropathy, toilets, and handwashing. Lancet 374: 1032–1035.
-
7.
Parvez SM, Kwong L, Rahman MJ, Ercumen A, Pickering AJ, Ghosh PK, Rahman MZ, Das KK, Luby SP, Unicomb L, 2017. Escherichia coli contamination of child complementary foods and association with domestic hygiene in rural Bangladesh. Trop Med Int Health 22: 547–557.
-
8.
Islam MS et al., 2013. Hygiene intervention reduces contamination of weaning food in Bangladesh. Trop Med Int Health 18: 250–258.
-
9.
Islam MA, Ahmed T, Faruque AS, Rahman S, Das SK, Ahmed D, Fattori V, Clarke R, Endtz HP, Cravioto A, 2012. Microbiological quality of complementary foods and its association with diarrhoeal morbidity and nutritional status of Bangladeshi children. Eur J Clin Nutr 66: 1242–1246.
-
10.
Kaul M, Kaur S, Wadhwa S, Chhibber S, 1996. Microbial contamination of weaning foods. Indian J Pediatr 63: 79–85.
-
11.
Oluwafemi F, Ibeh IN, 2011. Microbial contamination of seven major weaning foods in Nigeria. J Health Popul Nutr 29: 415–419.
-
12.
UNICEF, 2020. Improving Young Children’s Diets during the Complementary Feeding Period. New York, NY: UNICEF.
-
13.
Lanata CF, 2003. Studies of food hygiene and diarrhoeal disease. Int J Environ Health Res 13 (Suppl 1): S175–S183.
-
14.
Kung’u JK, Boor KJ, Ame SM, Ali NS, Jackson AE, Stoltzfus RJ, 2009. Bacterial populations in complementary foods and drinking-water in households with children aged 10–15 months in Zanzibar, Tanzania. J Health Popul Nutr 27: 41–52.
-
15.
Rahman MJ, Nizame FA, Nuruzzaman M, Akand F, Islam MA, Parvez SM, Stewart CP, Unicomb L, Luby SP, Winch PJ, 2016. Toward a scalable and sustainable intervention for complementary food safety. Food Nutr Bull 37: 186–201.
-
16.
Motarjemi Y, Kaferstein F, Moy G, Quevedo F, 1993. Contaminated weaning food: A major risk factor for diarrhoea and associated malnutrition. Bull World Health Organ 71: 79–92.
-
17.
Gautam OP, Curtis V, 2021. Food hygiene practices of rural women and microbial risk for children: Formative research in Nepal. Am J Trop Med Hyg 105: 1383–1395.
-
18.
Ehiri JE, Azubuike MC, Ubbaonu CN, Anyanwu EC, Ibe KM, Ogbonna MO, 2001. Critical control points of complementary food preparation and handling in eastern Nigeria. Bull World Health Organ 79: 423–433.
-
19.
Chidziwisano K, Tilley E, Malolo R, Kumwenda S, Musaya J, Morse T, 2019. Risk factors associated with feeding children under 2 years in rural Malawi—A formative study. Int J Environ Res Public Health 16: 2146.
-
20.
Bick S, Perieres L, D’Mello-Guyett L, Baker KK, Brown J, Muneme B, Nala R, Dreibelbis R, Cumming O, 2020. Risk factors for child food contamination in low-income neighbourhoods of Maputo, Mozambique: An exploratory, cross-sectional study. Matern Child Nutr 16: e12991.
-
21.
Ibrahim MK, Zambruni M, Melby CL, Melby PC, 2017. Impact of childhood malnutrition on host defense and infection. Clin Microbiol Rev 30: 919–971.
-
22.
Sheth M, Patel J, Sharma S, Seshadri S, 2000. Hazard analysis and critical control points of weaning foods. Indian J Pediatr 67: 405–410.
-
23.
Touré O, Coulibaly S, Arby A, Maiga F, Cairncross S, 2011. Improving microbiological food safety in peri-urban Mali; an experimental study. Food Control 22: 1565–1572.
-
24.
Touré O, Coulibaly S, Arby A, Maiga F, Cairncross S, 2013. Piloting an intervention to improve microbiological food safety in peri-urban Mali. Int J Hyg Environ Health 216: 138–145.
-
25.
Manaseki-Holland S et al., 2021. Effects on childhood infections of promoting safe and hygienic complementary-food handling practices through a community-based programme: A cluster randomised controlled trial in a rural area of The Gambia. PLoS Med 18: e1003260.
-
26.
Chidziwisano K, Tilley E, Morse T, 2020. Self-reported versus observed measures: Validation of child caregiver food hygiene practices in rural Malawi. Int J Environ Res Public Health 17: 4498.
-
27.
Mumma J, Simiyu S, Aseyo E, Anderson J, Czerniewska A, Allen E, Dreibelbis R, Baker KK, Cumming O, 2019. The safe start trial to assess the effect of an infant hygiene intervention on enteric infections and diarrhoea in low-income informal neighbourhoods of Kisumu, Kenya: A study protocol for a cluster randomized controlled trial. BMC Infect Dis 19: 1066.
-
28.
Chidziwisano K, Slekiene J, Mosler H-J, Morse T, 2020. Improving complementary food hygiene behaviors using the risk, attitude, norms, ability, and self-regulation approach in rural Malawi. Am J Trop Med Hyg 102: 1104–1115.
-
29.
Gautam OP, 2015. Food Hygiene Intervention to Improve Food Hygiene Behaviours, and Reduce Food Contamination in Nepal: An Exploratory Trial. Thesis, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom.
-
30.
Aunger R, Curtis V, 2016. Behaviour centred design: Towards an applied science of behaviour change. Health Psychol Rev 10: 425–446.
-
31.
Gautam OP, Schmidt W-P, Cairncross S, Cavill S, Curtis V, 2017. Trial of a novel intervention to improve multiple food hygiene behaviors in Nepal. Am J Trop Med Hyg 96: 1415–1426.
-
32.
Wendt AS, Sparling TM, Waid JL, Mueller AA, Gabrysch S, 2019. Food and Agricultural Approaches to Reducing Malnutrition (FAARM): Protocol for a cluster-randomised controlled trial to evaluate the impact of a homestead food production programme on undernutrition in rural Bangladesh. BMJ Open 9: e031037.
-
33.
Sobhan S, Müller-Hauser AA, Huda TMN, Waid JL, Gautam OP, Gon G, Wendt AS, Gabrysch S, 2022. Design, delivery, and determinants of uptake: Findings from a food hygiene behavior change intervention in rural Bangladesh. BMC Public Health 22: 887.
-
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