Food Hygiene

Food Hygiene: What changes are possible in practice?

DDOnline Dialogue on Diarrhoea Online Issue no. 56   March-May 1994

Food Hygiene: What changes are possible in practice?

Dr Cristina Monte, Dr Marilyn Nations, Unidade de Pesquisas Clinicas, Faculdade de Medicina, Universidade Federal do Ceara, CP 3229, Porangabussu, CED 60414, Fortaleza, Ceara, Brazil.

Grandmothers have experience and support to offer in introducing safer feeding methods.

While we have some knowledge about practices that contaminate food, much less is known about how to change behaviour so that contamination is reduced.  The challenge is to find which harmful practices can be changed. and how.

Our study took place in an urban resettlement community on the outskirts of Fortaleza, a major city in north-east Brazil. In 1987 the infant mortality rate in the region was one in ten live births; with half these deaths associated with diarrhoea.  By interviewing mothers of infants and observing what they did at home, we identified key behaviours likely to increase the risk of contamination of weaning foods.

  • 95 per cent of mothers did not wash their hands before preparing and giving infants food even though all households had soap and water.
  • Nearly all mothers used plastic feeding bottles that were neither washed with soap nor boiled before use.
  • Water stored overnight in unhygienic conditions was commonly used to prepare milk formulas or gruels without boiling it.
  • Storing prepared milk and gruels at room temperatures for later use was common.

We found that mothers who worked outside the home were more likely to keep food and re-use it for a second meal.

Four changes in behaviour were chosen for a one-month household trial.

  1. washing hands before preparing food
  2. boiling water for mixing powdered milk
  3. feeding gruel with a cup and spoon rather than a bottle
  4. feeding only freshly prepared milk and gruel

The reasons for selecting these changes as priorities were: they addressed common unhygienic practices; the changes were likely to reduce rood contamination; and they were identified by mothers as possible to put into practice.

Fifteen mothers who did not already practise these behaviours were assigned to each of the four trial groups. A fifth group of mothers was encouraged to practise all four behaviours. All the mothers were asked to assess together with the researchers how possible it was to introduce each recommendation. and to advise on how to improve the educational messages.

The trial showed that all the behaviour changes were feasible. Most mothers continued to practise the new behaviour throughout the one-month trial, and at least half of them practised the new behaviour at every feeding. The introduction of all four new behaviours together also proved possible. Mothers did not find the changes too overwhelming – each change helped reinforce the others. Mothers’ motivation in the group trying all four recommendations was greater than in the other groups because they felt pride in meeting the challenge of carrying out all four behaviours correctly.

The most difficult behaviour to promote was feeding with a cup and spoon. This was because it requires more time and effort by the mother, and bottle-fed babies may find it difficult to adjust to being fed with a spoon. Even so, most mothers (53 per cent in group 3, and 60 per cent in the ‘all four’ group) managed to do it at every meal.

Our findings suggest that mothers are willing to change their behaviour for the sake of their infants if given the right support. Local culture gives respect to mothers who are ‘ciudadosa’ – loving, careful, organised and willing to learn.

The trial has several lessons for other health projects.

  • Mothers know best what is feasible
    Using the experience and knowledge of mothers is crucial to achieving behavioural change. Mothers can give a realistic picture of life inside their homes and are good judges of what changes will work, and whether some changes will place too great a burden on their workload.
  • Do not try to change practices associated with strong beliefs
    When a suggested improvement clashes with a mother’s beliefs it is better to abandon it. Try to find a more acceptable alternative that will achieve the same effect. For example, mothers strongly believed that storing water overnight was necessary to release ‘the sun’s heat’. The project did not try to change this, but instead encouraged mothers to boil water for mixing powdered milk to be added to gruels.
  • The richest resource is mothers’ potential
    Mothers’ abilities to ensure that their infants grow up healthy and strong are clearly valued in many cultures. Health workers in other countries need to find out local beliefs (such as ‘cuidadosa’) that can be promoted to encourage women’ s potential.