Om's Blog: reporting progress on a food hygiene intervention to improve food hygiene behaviours, and reduce food contamination and diarrhoeal disease burden in Nepal
18 October 2012
Om Prasad Gautam is a public health professional with more than 10 years experience working in various organisations including WaterAid, the World Health Organisation and the Programme for Immunisation-Preventable Diseases. His experience includes programmes related to water, sanitation and hygiene (WASH), child health, immunisation, diseases surveillance, HIV/AIDS, cross-sector coordination, public health disaster, HR management and equity and inclusion.
Om is now embarking on his study into a ‘food hygiene intervention to improve food hygiene behaviours, reduce food contamination and diarrhoeal diseases burden in Nepal’. Om has designed a study with an aims to implement a simple, feasible and replicable food hygiene intervention and assess the effect of this intervention on mothers’ food hygiene practices, and to assess the impact of the interventions on the level of microbiological contamination in food and diarrhoeal diseases burden. The study will also explore how food hygiene interventions can be integrated into nutrition, health and WASH policy and programmes in Nepal.
This blog will track Om’s progress during his intervention study in Nepal.
Happy New Year readers!
As promised in my last blog, I am delighted to be able to share with you a 19 minute video which documents all phases of the ‘Safe Food, Healthy Child’ campaign.
In sharing this documentary, I hope provide insights on how behaviour change programmes should be designed, implemented and evaluated. As such, the short film not only demonstrates how the behaviour change campaign was implemented but also highlights the innovative and creative approach taken throughout the design and implementation phase of the food hygiene intervention in rural Nepal.
Please note: this video is educational and I’d kindly request that all viewers refrain from using this video for any other purposes e.g. commercial purposes. The intellectual property and copy rights are reserved with the PI of the study, Om Prasad Gautam.
I’ve been quiet for the last few months as I’ve been busy analysing and writing-up my trial papers which will be submitted for publication soon. I am back now though to bring you the latest updates from the food hygiene intervention in Nepal.
I hope you had a chance to check out the preliminary findings of the trial which I published in poster format a couple of months ago. This month, I’d like to share with you the core components of the food hygiene intervention I designed which aimed to improve food hygiene behaviours and reduce food contamination and the diarrhoeal disease burden in Nepal.
How was the campaign carried out?
The campaign exposed mothers, with children aged 6-59 months, to a food hygiene intervention which was comprised of six community/group events and six household visits. Each event/visit had a specific goal such as: raising awareness of and eliciting commitment to the campaign, reinforcing desired behaviours/programme rituals/food hygiene behaviours, establishing group norms/habits, and ensuring the sustainability of the campaign.
These goals were to be achieved through varying activities which themselves were linked to key motivational themes. The activities included but weren’t limited to: storytelling and motivational games, the introduction of an ‘Ideal Mother’ figure, the demarcation of kitchens with ribbons, flags and eye-level danglers reminding mothers of the five key food hygiene behaviours, screening of a brief video, the installation of the programme jingle as a ring-tone on mothers’ mobile phones, the use of glo-germs and 3M PetriFilm to demonstrate contamination, public pledges of commitment to the campaign, the launch of three competitions – the ‘Clean Kitchen Competition’, the ‘Ideal Mother Competition’ and the 'Safe Food Hygiene Zone Competition' – and public reward ceremonies.
Other tools used in the intervention and a further campaign video will soon be published, so watch this space.
After the completion of the food hygiene intervention trial in early September, four major activities were performed between September and December 2013. In this blog, I would like to update you on the details of these activities, namely: i) multi-sector policy analysis, ii) trial outcomes measurement, iii) trial compliance measurement and iv) dissemination of findings at national level.
I. Multi-sector policy analysis:
To explore how a food hygiene intervention might be integrated into sector strategies and programmes for nutrition, health, WASH, food technology & quality control in Nepal, I reviewed various government sector policies, strategies, and programme guidelines. Any policies, strategies, programme documents within the timeframe of 1990-2013 were included for the review, which I did between mid September and mid October of last year. Altogether nine key documents were reviewed for health sector including the “Nepal Health Sector Programme-II (2010-2015)”; three key nutrition sector documents, including the ‘Multi-Sector Nutrition Plan (2013-2017)”; six key WASH document, including the “Sanitation and Hygiene Master Plan (2011); and four key food technology & quality control documents, including the “Food Act and Minimum Quality & Quality Standard for Food”. Policy and programme adherence to food hygiene and its programmatic gaps, institutional responsibilities and barriers, as well as possible ways and opportunities for integration were highlighted. In addition, to triangulate the desk review findings and identify current practices on implementation of food hygiene-related programme/activities, key informant interviews were conducted with 12 policy and programme development professionals. Key informants included the sectoral ministry/department and key donor/INGO personnel directly engaged in the relevant areas.
II. Measurement of trial outcomes:
The trial outcomes were only measured 45 days after completion of the intervention. The food hygiene behaviours of mothers (with a child aged 6-59months) were observed, and food, milk and water samples were tested to assess the level of contamination (microbes). Period prevalence of diarrhoea among young children (6-59months) was recorded from both the “intervention” and “control” arms.
Structured observation of mothers’ “food hygiene behaviours”:
To observe behaviours, 25 food hygiene observers (FHOs) were recruited, given skilled and field based training, and mobilized accordingly. In each house, the observations took place from 1 to 5pm, when the behaviours of interest were likely to be seen
Observers paid particular attention to key food hygiene behaviours and recorded them accordingly. To minimize the effect of the presence of the observers, participant mothers were told that this was a daily routine assessment of mothers. Observers were only allowed to use a notebook ,and were requested to talk about recent rituals/events in the village and minimize gossiping in the mother’s house to provide focused attention on the mothers’ behaviours.
Observers had to fill the checklist immediately after their return home from the field, using notebook details, and submit the form the very next day to our field staff. Within 12 days, all mothers’ behaviours from eight clusters from both study arms (120 HHs in intervention group and 117 HHs in control group) were observed and a day review meeting with observers was conducted to document their learning.
Microbe assessment in food, water and milk:
Like with the baseline, altogether 248 food samples, 80 water samples and 45 milk samples were collected from the eight clusters (from both the intervention and control groups), using a standard protocol. The collected samples were then transported into a lab, maintaining an adequate temperature (<60C), and samples were processed, homogenized, inoculated, incubated. Results were then interpreted using standard operating guidelines. 3M PetriFilm for food & milk and membrane filter & Hi-chrome coliform media were used for water samples test. From all the samples, the total number of coliforms and E.coli were (CFU/gram in food and CFU/100ml in water) quantified.
Diarrhoea period prevalence measurement:
To measure the effect of the intervention on diarrhoea prevalence, all mothers from eight clusters with a child aged 6-59months were asked if their child had had diarrhoea in the last 7 days. If yes, then the WHO definition was used to confirm the case i.e. ‘the passage of 3 or more loose or liquid stools per day or more frequently than is normal for the individuals’.
III. Trial compliance measurement:
To ascertain whether or not the intervention reached the intended target groups and to assess the exposure and reach of the intervention, the compliance measurement was done in both the intervention and control arms.
In this exercise, mothers were asked whether they have heard of, attended or followed campaign events/visits.This measurement was extremely useful in assessing whether there was any cross-contamination during the trial period. In addition, mothers from only the intervention group were asked to rank the behaviours taught in the trial using an illustration according to how easy or difficult they were to perform.
Through focus group discussions, we had also tried to capture the key motivational factors/tools/approach for mothers to change and adopt key food hygiene behaviours. We also asked mothers questions that helped us explore whether change in behaviours over time has any role in changing social norms.
IV. Dissemination of the findings at national level:
A national dissemination workshop was organized in Kathmandu on 10th December 2013 after successful accomplishment of the trial. Here, I presented and shared the full findings obtained from formative research, as well as the preliminary findings of the food hygiene intervention trial and policy analysis. The outcomes of the trial were well received and there was lots of positive feedback. A 19 minute video documentary of the trial was also shared during the event. In order to demonstrate and provide an opportunity to have a look at the tools/materials used for the programme, a display stall was set-up. More than 60 distinguished guests, including colleagues from the Prime Minister Office, National Planning Commission, the health, WASH, nutrition, agriculture, education, and food technology sectors, as well as donors and NGOs attended the workshop.
After completing all my field work, I am now back in the UK. I will be sharing the results of the trial in my next blog.
I am delighted to continue sharing the progress of the food hygiene intervention trial. I have been in the field during the last three months for the trial, with limited connectivity, but I am pleased now to be able to share reflections and photos on the community/group events and household visits connected with the trial.
The first household visit:
After launching a food hygiene intervention trial in each cluster and creating a campaign movement, which I discussed in my earlier blog, our Food Hygiene Motivators (FHM) carried out the first household visit in each intervention household (with a total of 120 households).
This visit was instrumental to changing the physical settings in the kitchen. It was common to find the kitchen area set within the household’s only room, which was used for everything from cooking and sleeping to keeping animals, from buffalos to chickens. After cleaning this room, the kitchen area was demarcated with coloured ribbon and flags were put up highlighting the five key food hygiene behaviours that are encouraged. To remind mothers about these behaviours and reinforce them, small eye danglers, an ‘ideal mother’ board and Dhungro were put up in specific places in the kitchen.
The danglers were put-up in the area where the behaviours should be encouraged, so that a ‘hand washing’ dangler was next to the kitchen hand washing station, the ‘thorough cooking’ dangler was placed in the cooking area, and the ‘symbol-of-milk’ dangler in the nearby milk storage area.
After the kitchen makeover, the FHM highlighted the importance of the five food hygiene behaviours and diarrhoeal prevention mechanisms by showing the mother the 3D flip chart.
The programme song was installed as a ring tone on the mothers’ mobile phone, for those who had one. This process was carried out in each intervention household within 15 days of the first community event.
The first group event:
Following the first household visit, the first group event was organized in each of the 12 sub-clusters.
The main purpose was to involve the mothers to practice the five key food hygiene behaviours, introduce the 3M petrifilm, glo-germ, as well as the message bibs, and start the ‘clean kitchen’ competition.
The practical demonstration session was instrumental in ensuring that mothers performed all key behaviours properly. The use of 3M PetriFilms was key to demonstrating how thorough cooking and re-heating kills bacteria. The use of glo-germ inon the hands of mothers and children before feeding eally illustrated the importance of hand washing.
The introduction of the bib containing messages like ‘did you wash your hands before feeding me?’ was really innovative.
At the end of the session, the ‘clean kitchen’ competition and the indicators used for judging it were announced, and mothers were given a month within which to get their kitchen ready. The FHM showed households the visit schedule, which constitutes one visit to each household every 15 days.
The second household visit:
This visit was undertaken in each household during cooking time and the FHM reinforced all the actions performed during the group event. Mothers were also reminded about the ‘clean kitchen’ competition and encouraged to win.
The second group event:
By the time of the second group event, there was lots of excitement and enthusiasm among them towards the programme. This event was organized in a public place, and we used nurture as a key motivational factor to change the food hygiene behaviours of mothers through real life demonstrations, such as, for example, the ‘Child Life Game’, folk songs and puzzle games. The session began with the usual campaign ritual of cutting nails, washing hands, dancing to the campaign song and sharing experiences. Following this, a ‘Child Life Game’ was performed, where the consequences of whether or not a mother practices all five food hygiene behaviours were demonstrated, including what will happen to their children in the future.
To play, the FHMs highlighted a situation: Krishna’s mother followed all five food hygiene behaviours while he was growing up so that Krishna was successful when he reached 8 years, 16 years, 25 years and 29 years of age. On the other hand, Hira’s mother didn’t follow the behaviours and Hira was unsuccessful in life. The mothers were amazed to see the real differences in life progress between the two characters played out in front of them. Almost all mothers said that ‘they want a child like Krishna and they will make it happen by performing all five behaviours’. The ‘folk song competition’ was engaging, lively and humorous. The mothers sang the song they had composed using food hygiene messages and danced. At the end the ‘ideal mother’ competition was announced, and the indicators for it were shared. Mothers were given one month to work towards these and compete for the title. A fan reflecting all five behaviours was also provided to mothers to remind them of the indicators.
The third household visit:
Through this visit, the FHM observed and guided re-heating practices of different food, so that mothers were able to understand how much time is needed to properly re-heat different foods. Mothers were also encouraged to use the kettle to boil water and to boil the milk each time they feed their child.
An interactive discussion using 3D flip charts and 3M PetriFilm was also performed with the mother and household family members. Mothers were encouraged to win the ‘clean kitchen’ and ‘ideal mother’ competitions. During this period, mother’s kitchens were closely monitored by the FHM, Research Assistant, Coordination Committee members and myself, using clean kitchen indicators.
The third group event:
Mothers were curious to attend this session because the winner of the ‘clean kitchen’ competition was to be announced. In this event, we used disgust as a motivational factor to change mother’s behaviours by doing a ‘disgust exercise’, using glo-germ to internalise how the germs can be transmitted from mother’s hands to serving utensils, the child’s food, and finally to the child’s stomach. We also played the hot potato game which showed how social exclusion results from unhygienic food behaviours. In addition, we used social pledging and respect as a motivational factor to change behaviours. Almost 85% of mother’s won the ‘clean kitchen’ competition. The winners received a prize, a congratulation poster, and shared their success story> All participants visited the winners’ houses to observe the clean kitchen. Those who didn’t win this time got an extra 15 days to clean their kitchen based on clean kitchen indicators. At the end, the “safe food hygiene zone” competition was announced. This is and an intra-cluster competition.
The fourth household visit:
The fourth household visit was a little different from the previous one. A peer review exercise, also known as the watch-dog exercise, was performed. The mothers observed each other’s behaviours and reported back the outcomes to the FHM. This way, mothers were peer pressurized to perform all five behaviours. Mothers were also reminded of the ‘ideal mother’ and ‘safe food hygiene zone’ indicators and encouraged to participate in the competitions.
The fourth group event:
This was again an interesting event for all participating mothers because the ‘ideal mother’ title would be awarded for those who had been practicing all five key food hygiene behaviours. In this event, we used social respect and affiliation as a motivational factor to change mothers’ food hygiene behaviours through an innovative letter exchange, family members role-play, and public pledging for those who won the ‘ideal mother’ title. A surprise letter from an unknown mother of a neighbouring village came to the participating mother. The letter, sent by a mother called ‘Dhukhimaya’, was read out, highlighting the problems she is facing because her child has been getting frequent diarrhoea over the last few months. The mothers felt that they should support Dhukhimaya and sent back a letter to her after intensive discussion about possible solutions. This was a really emotional moment.
A ‘role play’ by mothers acting as a key household family member to highlight the social, environmental and attitudinal barriers related to food hygiene behaviours was also performed. Among four role play mothers, one performed the role of an ideal mother showing a positive attitude and action towards all key behaviours, another performed the role of a positive but ignorant husband, another performed the role of a resistant child, and yet another of a mother in-law with an ignorant and resistant character.
The idea was to demonstrate how an ‘ideal mother’ can overcome these different barriers at home to be able to practice all five behaviours. There was lots of excitement and enthusiasm when 99% of the mothers won the ‘ideal mother’ title. Mothers who won received a prize, and their photos were put up in the village junction for their social respect and pride.
The fifth household visit:
In this visit, the FHM observed mothers’ behaviours and asked them to self review their performance in front of other family members, neighbouring people and the FHM. In the end, mothers were reminded about the ‘safe food hygiene zone’ indicators and their role in making the cluster a ‘safe food hygiene zone’. During this visit, mothers were also asked which particular session and tools they like more and want to observe again in the final community event.
During the trial period, a few school events were also conducted in those schools within the intervention clusters, and various planning and review meetings were conducted with the FHMs to assess the ongoing progress as well as to properly plan for the different events.
The second and closing community event:
Mothers as well as villagers were really excited to attend this event. Altogether four community events were conducted in four intervention clusters. The closing event reinforced ideal behaviours. It was instrumental in declaring the cluster a safe food hygiene zone, sharing programme success stories, and publically pledging mothers, coordination committee members and all supporters to continue their good work. The event also began with the campaign ritual described above.
Guests from different institutions attended the event such as professionals from the Ministry of Health & Population, the WaterAid Nepal Country Representative, VDC secretaries, local health institution heads, coordination committee members, local teachers and social leaders. There was very good attendance by mothers and family members, as well other villagers.
A reply letter received from Dhukhimaya was read-out saying that she had found the fellow mothers’ suggestions extremely useful and that her child no longer had diarrhoea.
The sessions which mothers had reported to have found the most useful and motivational throughout the campaign were performed again at this event, including the ‘Child’s Life Game’, the folk song competition and the role play. As Principal Investigator for the study, I highlighted and shared the operational learning, and the success of the programme, as well as the challenges faced during the trial implementation.
The huge “wow!” came when 11 out of the 12 sub-clusters were declared as a ‘safe hygiene zone. Mothers were really pleased to receive a safe food hygiene zone billboard and they made a public commitment to sustain the five behaviours as well as to maintain the safe food hygiene zone. For continuous follow-up and monitoring, volunteer mothers were selected from each sub-cluster. On behalf of the programme, I publically pledged all mothers, coordination committee members, research assistants, FHMs, local social leaders and distributed a “certificate of appreciation”. It was also exciting to listen to the positive words on how the campaign was an inspiration, to hear the thanks from all guests and coordination committee members, and to receive good bye tikas and mala from mothers.
To fix the static ‘safe food hygiene zone’ billboards in the respective places, all participants and guests marched towards the village chanting ‘safe food, healthy child’, ‘ideal mother hi hi, diarrhoea bye bye’. The rally was huge and mothers were singing the song and dancing using local music. When the event was over, mothers and our staff were really emotional when saying goodbye.
The sixth household visit and a two-day review meeting on completion of the trial:
In this visit, the three month household-level action plan was reviewed. A household-level sustainability workplan was also developed. Mothers and family members were motivated to continuously sustain food hygiene behaviours and optimum utilization of received materials.
Key learnings, field experiences and the challenges faced by the FHMs were documented through a two-day residential review meeting. The usefulness of all tools as well as the most exciting and not so exciting things were also noted. Experience certificates and tokens of appreciation were provided to all FHMs, and local stakeholders and team members recognizing their valuable contribution to the programme. I heartily appreciated the tireless efforts and work done by the FHMs and their contribution throughout the trial periods. Dr Val Curtis also joined in the final review meeting through Skype and thanked all FHMs for their hard work throughout the intervention period. Among the FHMs, the best food hygiene motivators and most progressive motivators were also celebrated and were highly appreciated for their contribution. The FHMs were really emotional when they were saying goodbye and I felt the same.
I am very excited to tell you about the recent launch of the ‘Food Hygiene Intervention Trial’ in four intervention clusters in Kavre district of Nepal. Altogether 12 launch events took place and community participation was really encouraged. The Regional Health Director from the Ministry of Health & Population, Village Development Committee secretaries, members from project coordination committees, teachers, and local social or political leaders participated in the launch event as guests of honour. As I mentioned in my earlier blog, the campaign will be implemented over three months and six community events and six sets of households visits will be performed during this period.
The main purpose of the first community event was to launch the food hygiene intervention trial, using the concept of an ‘ideal mother’ and the motto ‘safe food, healthy child’ to inform mothers and community members about food hygiene and encouraging behaviour change.
Just a day before the event, food hygiene motivators (FHM) visited alltarget households and their neighbouring households and handed over theinvitation card to attend in the programme. On the event day, the FHMs prepared the event space with banners and music. All guests were warmly welcome on arrival and invited to take a seat after cutting their fingernails and washing their hands with soap. Guests were then given an overview of the food hygiene programme before some FHMs danced to the programme song. One of the guests of honour gave an overview of the objective of the three months programme.
To start, FHMs reflected on the current situation of the village by telling story, using images and video clips showing current food hygiene practices representing ‘disgusting’ and ‘safe’ behaviours. Using a flip chart, FHM highlighted five key food hygiene behaviours which they linked with the concept of an ‘ideal mother’. The social, economic and public health importance and benefits of performing five key food hygiene behaviours were carefully articulated.
Next, one of the guests of honour made an appeal to all mothers tocommit to performing the five key food hygiene behaviours. Mothers were then asked to take an oath . before they were presented with a ‘commitment certificate’ and the FHM began to schedule the first household visit starting the very next day . At the end of the programme, all participants and guests marched through the local area to the food hygiene programme song, holding flags showing the programme logo and chanting ‘safe food, healthy child’ and ‘we want, ideal mother’.
The launch event was followed as soon as possible by the first household visit. The aim of this visit is to brief all family members about the food hygiene campaign and its objectives, perform a kitchen makeover, reinforce five key food hygiene behaviours, and prepare a three month action plan for each household. Each FHM is responsible for around 10-12 households and each first household visit takes at least one day. Following key actions were performed by FHM during their households visit.
We identified eight suitable clusters against our inclusion and exclusion criteria, four from each village development committee. In each cluster, households with a mother having a child aged 6-59 months were identified and recruited to the study after receiving consent from the child’s mother. Altogether 239 eligible households were recruited, Together with trained data collectors I visited all households to collect socio-demographic information. Data entry was done using SPSS and frequency analysis was performed to observe the similarities and differences between the eight clusters.
Ahead of the intervention, we then moved on to conducting the baseline research. More detail on each step in the baseline study process is given below.
25 food hygiene observers (FHOs) were recruited to observe study participants’ food hygiene practices. I provided intensive skill and field based training to all FHOs before they embark to observe mother’s food hygiene behaviours. Five key food hygiene behaviours(see January 2013 blog post) were observed simultaneously in each cluster over a ten day period. At least three observers were mobilised in each cluster to observe behaviours and precautions were taken to minimise influence or un-identical bias in mother’s behaviours during observation. FHOs paid particular attention to food storage, cleanliness of serving utensils, handwashing before feeding, re-heating child’s food, and water/milk treatment before feeding. I closely monitored the observer’s work during that period. I was so happy to find such motivated, confidential and strong FHOs to inspect the behaviours of mothers without any difficulties in the given timeframe.
To assess the level of contamination (coliforms and E.coli) in commonly used children’s food, I have been working with a lab in Kathmandu. The food, water and milk samples were collected from the field using trained lab technicians. Altogether 248 food samples, 80 water samples and 45 milk samples were collected from the eight clusters using a standard protocol. Lab technicians collected from each household 50ml of milk, 250ml of water and 50g samples of child food at four key stages: immediately after cooking, while feeding, after 5hrs storage and immediately after re-heating. The collected samples were transported in sterilized containers to the Kathmandu lab the same day, taking care to maintaining the appropriate sampletemperature. For food and milk samples, 3M PetriFilm (E.coli/Coliforms count plates) were used and for water, membrane filter and Hi-chrome coliform media was used. All collected samples were processed, homogenized, inoculated, incubated and results were interpreted using standard operating guideline prepared for this food hygiene intervention trial. Each household from which food samples were collected received NRs 200 which is the equivalent cost for the amount of food collected.
Diarrhoeal status measurement
During behaviours assessment, mothers were asked if their child aged between 6 and 59 months had had diarrhoea in last 7 days. WHO definition of diarrhoea was applied to confirm that reported cases were actual diarrhoea. All baseline data were entered into SPSS for further analysis.
After the baseline measurement of socio-demographic and pre-intervention outcome measurement, I checked the comparability of different clusters. The eight clusters were randomized into intervention and control clusters by tossing coin in 4:4 ratio. This ensured that each cluster had an equal chance to be in either group.
Recruitment of food hygiene motivators (FHMs)
The Food Hygiene Motivators (FHMs) are the key resource in my intervention for to transferring knowledge and motivating mothers to practice simple and safe food hygiene practices using the ‘Food Hygiene Promotion’ package. 15 food hygiene motivators were locally recruited to implement the programme for at least three months. I have received support from the Project Coordination Committee to announce the candidature requirements and to select the qualified, motivated candidates after performing intensive assessment including group discussion, one to one interview and reference checks. All promoters have at least school leaving certificate education and or similar capacity with the Nepal’s Female Community Health Volunteers (FCHVs).
Five days skill based training for FHMs
A five-day residential skill based intensive training programme was organized for all motivators in order to enhance their food hygiene knowledge and skills to execute promotion package. Training was organized to improve the FHMs’ technical capacity, skills to conduct community events and households visit, as well as their interpersonal communication skill. The training aimed to ensure that FHMs could implement the food hygiene promotion package independently or with limited support. I was extremely pleased to train and develop such a strong team of FHMs.
Conducted pre-trial activities
Before running an actual trial, I wanted conduct a test run of the intervention package to identify any problems or difficulties. It was also essential to build the confidence of FHMs before the actual intervention. As planned, the pre-trial activities were performed among 21 households using same methods, procedures, techniques, and using the same tools/materials referring to programmeimplementation guideline. All FHMs were actively involved, giving them the change to practice the whole intervention package with participating mothers in real life scenario. The actual feasibility and relevance of each session and the corresponding materials was also tested during pre-trial sessions. This helped us identify any practical difficulties which might occur while executing actual trial. FHMs also had the chance to experience some real life challenges that might occur and they are now prepared to address such difficulties while executing the actual intervention package in real settings.
In my next blog, I look forward to telling you all about the campaign kick-off and trial implementation progress!
My work has been extremely busy and exciting since my last blog about the visit to Nepal from Dr Val Curtis, my PhD supervisor. During this time, my team and I have worked hard to finalise a simple & scalable 'food hygiene promotion package.' The final package includes lots of motivational tools, materials, demonstration and public pledging exercises. Our aim was to avoid traditional behaviour change tools such as posters or leaflets, and instead using more creative tools.
The food hygiene promotion package was designed using a campaign approach. The campaign centred on an 'Ideal Mother Concept' with supportive branding such as a logo, colour scheme, and a kitchen makeover plan. The package was designed to be implemented over three months, which includes six community events and six household visits to motivate mothers to practice safe food hygiene behaviours. We developed a campaign implementation guideline that provided detail sessions plan for each events or visits. Each event is designed around a specific motivational theme such as nurture, disgust, affiliation and social respect. Each event engages different tools and materials, while linking five prioritized positive behaviours.
The package includes various tools including storytelling, situation analysis flex, video clips, 3D flip charts, demarcation of the kitchen using branded ribbon and flag, public commitment & use of commitment certificates, use of glo-germs, eye danglers (main board highlighting five behaviours, small danglers linking with each behaviours, fan, fire blowing instrument), folk song competition, teach the participants demo exercise, public pledging, musical chair game, disgusting exercise, child's real life game, puzzle game, innovative letter exchange, peer review exercise, pile shorting, ideal mother competition, clean kitchen competition, safe food hygiene zone declaration and so on. As you can see, there we are using a great number of materials and tools and it is difficult to describe them all here! However, here are a few photos of some of the materials to give you a flavour.
This month, I received a visit from my PhD supervisor Dr Val Curtis to Nepal so that she could review my work in Nepal to date and provide her expert input regarding the food hygiene intervention package and the field site for my trial.
The first appointment in Val’s visit was a one-day intensive workshop with the creative team who had been working on the food hygiene promotion package. Val gave valuable feedback on the prototype intervention, which will help us to shape final package.
The next day, Val and I visited the field site which is 45km east of Kathmandu valley. Together we visited two villages, where Val spoke with several households and participated in discussions with mothers of young children. We also met with project coordination committee members and Female Community Health Volunteers who will be key to the role-out of the food hygiene intervention package.
The following day, Val provided her feedback on the prototype food hygiene intervention package based on her field visit observation. After discussions we decided to position the campaign using the concept of an ‘ideal mother’. Later the same day, Val and I also visited the laboratory which will be conducting the microbiological testing for my study.
That evening, Val and I were invited to an evening reception organised by WaterAid Nepal. Val was invited to give a presentation on global and regional perspectives on hygiene, handwashing and behaviour change. The reception was attended by representatives from the WASH, Health and Nutrition sectors as well as the private sector.
On the last day of Val’s visit, we planned next steps for my study such as the baseline survey and randomization process before Val boarded the plane back to the UK.
In my first blog post, I gave an overview of my PhD research which involves designing a food hygiene intervention, assessing the effect of this intervention on mothers’ food hygiene practices, and finally assessing the impact of the interventions on the level of microbiological contamination in food and diarrhoeal diseases burden.
In the second phase of my PhD research work, I am taking up the challenge to design a simple and scalable food hygiene intervention which will then allow me to measure the effects of this behaviour-change intervention on mother’s food hygiene behaviours and the level of contamination in child’s food and diarrhoeal diseases among young children.
After having arrived in Nepal from the UK, I have been in-depth detail to get more insights on five prioritized behaviours to design a simple and scalable food hygiene promotion package. These five food hygiene behaviours were chosen after assessing current food hygiene behaviours of mothers in my study area and their determinants, microbes in child’s food and identifying critical and behavioural control points,. The resulting food hygiene promotion package has been designed in such a way that it will help to motivate mothers to practices and habituate the following prioritized behaviours:
1. Thorough cooking of child’s food (identified as critical control point but not prioritized as many mothers currently practicing)
2. Cleaning of serving utensils using ash or soap before putting cooked/re-heated food into serving utensils
3. Handwashing with soap before feeding (mother) and eating (child)
4. Store cooked or leftover food in container with a tight fitting lid to protect from flies, dust and dirt
5. Thorough re-heating of leftover or stored food
6. Boil milk and water before serving
A comprehensive creative brief was produced which highlighted prevalent behaviours, social, physical and environmental barriers, and motivational factors for each of the above six food hygiene behaviours. As I had previously planned in research protocol, a creative team was formed with members from different expertise and professional exposure and experiences of designing and developing a behaviour change and communication package. After receiving a detailed presentation on the prioritized behaviours and creative briefing regarding developing a simple and scalable food hygiene promotional package, the creative team visited study area to allow them to better understand the context, feasibility, setting and socio-cultural aspects.
With the support received from the creative team, I have developed a food hygiene promotion package that will be easy to replicate in a wider community. While designing the intervention, emphasis was placed on community mobilization, inter personal communication and print media.
The food hygiene promotion package includes various innovative tools and techniques which will motivate mothers to improve the aforementioned six key food hygiene behaviours. Such tools include storytelling, video clips, flex, folk songs / ring tones, ‘ideal mother’ concept, walkathon, public appeals, use of glo-germs, ‘beeps’, ‘teach the friends’ session, flip charts, clean kitchen competitions and demonstrations, puzzle games, household observation, role model exercises, folk song competitions, musical chair games, declaration of ‘ideal mothers’, ‘ideal mothers’ posters and photos in the village, watchdog exercise (peer review exercise), public pledging, declaration of safe food hygiene zone, distribution of appreciation certificates and so on.
The whole food hygiene promotion package will be delivered within three months through six community events and six household visits by 15 locally recruited ‘food hygiene promoters’ in four intervention clusters. A five day training session will be provided to all food hygiene promoters to improve their technical knowledge on the subject and develop their skills in conducting community and household-level events using the package. To make local stakeholders accountable in this intervention study from inception, the project coordination committee has been formed under the chairmanship of village development committee secretary with representatives from local health institutions, local social leaders as well as myself in both the village development committees. The Child Health Division and the Ministry of Health and Population (a local collaborator) have already circulated a letter to the respective district to ensure collaborative support of the intervention study through their local health institutions.
Dr Val Curtis, Director of the Hygiene Centre at LSHTM and my PhD supervisor, is joining us in late January 2013 to provide her expert inputs on the overall intervention package to help facilitate and finalize the intervention. I’m looking forward to warmly welcoming Dr Val to Nepal, and I will update on her visit in my next blog post.
As soon as the prototype intervention package is finalised, it will be piloted in its entirety before it is then finalised and implemented in four intervention clusters. The baseline of the study will be conducted in March 2013 to set a benchmark to compare the effects of the intervention through a follow-up study after intervention is implemented.
In my next blog, I will write more on intervention package finalisation process, update on Dr Val’s visit to Nepal, the baseline study, cluster randomisation and recruitment.
I have long been interested in food hygiene as an aspect of public health. Preventable and treatable food-borne diseases are a major cause of illness globally and inadequate food hygiene is likely to cause a substantial proportion of foodborne infections including diarrhoea among infants and young children. Although our instincts tell us that proper food hygiene practices may prevent disease, there is little rigorous evidence to support this premise from developing countries. Very few intervention studies have been carried out and there has been little effort to undertake food hygiene interventions for the reduction of childhood diarrhoea and malnutrition. A simple and replicable food hygiene intervention, which can be implemented by the WASH, health and nutrition sectors at scale has yet to be designed and tested. My PhD research aims to fill this gap.
My research has two phases using two distinct research designs. I have already completed first phase. Phase One of the study wasconducted in a rural hill setting in Nepal during April to June 2012. This formative research examined mothers’ food hygiene practices and their environmental and psychological determinants, the level of microbes in the child’s food, and critical and behavioral control points. I used my research findings to prioritise five key food hygiene behaviours for the design of an intervention in the next phase. I delivered the findings of my formative research in my upgrading seminar at LSHTM in September, which I am pleased to say went successfully.
I am now getting ready to leave the UK to embark on Phase Two of the study; a cluster randomized, Before-After study with Control (BAC). This second phase will be conducted in eight randomly-selected clusters. Each cluster represents around 28 households, and the eight clusters will be arranged into four ‘intervention clusters’, and fours ‘control clusters’. I will design, test and implement a food hygiene intervention targeting mothers that have young children (6 to 59 months), which will be based on the five priority food hygiene behaviours I determined in Phase One. The primary outcome of interest of this research is sustainable improvements in mother’s food hygiene practices as a result of intervention. The secondary outcome is the effect of the intervention on the levels of microbiological contamination in food and on diarrhoeal diseases.
The design, testing, implementation and effect measurement of the intervention will take one year. During this year I will:
• Develop a prototype intervention and assess feasibility
• Do baseline measurement, cluster randomisation and recruitment
• Conduct an intervention field test and pre-intervention outcome measurement
• Implement the intervention
• Measure the effect of and compliance with the intervention
I am excited to be returning to Nepal to continue my second phase of the research there. In the following editions of this blog, I will keep you up to date with the progress of my work.