Om's Blog: Insights from a food hygiene intervention study in Nepal

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.

January 2013: Developing a prototype food hygiene promotion intervention and assessing its feasibility  

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.  

October 2012: Getting ready to return to Nepal for second phase of the study 

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.