Diarrhea Prevention Through Food Safety Education

Mini Sheth and Monika Obrah

Department of Foods and Nutrition, M.S. University of Baroda, Vadodara, Gujarat, India.

Abstract. O b j e c t i v e : Food safety education (FSE) was imparted in order to reduce the prevalence of diarrhea in children
and improving the knowledge, attitude and practices of mothers regarding safe feeding practices. Methods : The study was
conducted on mothers (n=200) of underprivileged children (6-24 months) through Anganwadi workers (AWW). The food safety
education package incorporated three messages: washing hands with soap and water, avoid feeding leftover food and keep
surrounding clean. These were imparted using lectures, slogans, posters, charts, flash cards, role-play. Calendars and leaflets
were also handed over to the mothers as education material. After food safety education intervention, the households were
studied again as at the baseline, on various aspects. R e s u l t : There was 52% reduction in the incidence of diarrhea. The
environmental sanitation and personal hygiene scores of most of the households and mothers improved. Improvement in the
practice of hand-washing and avoidance of feeding leftovers to children was seen. There was reduction in the microbial load
in the hand rinse samples of both mothers and children. Conclusion : AWW proved to be effective change agents and FSE
was successful in bringing about a positive behavior modification in mothers. [Indian J Pediatr 2004; 71 (10) : 879-882]
E-mail : mkss7 @hotmail.com

K e y words : Food safety; Diarrhea; Children; Behavior modification; Mothers; Education.

Diarrhea continues to plague the developing world, educated the mothers.

resulting in more than 3 million deaths. Children
especially those who are malnourished remain at a greater
risk. More than 1.5 billion episodes of diarrhea have been
reported in the children below 5 years resulting in over 3
million deaths. 1,2 Besides, contaminated water,
contamination of food also play an important role in the
etiology of diarrhea. 3,4The chances of food contamination
and cross contamination, become higher especially in the
lower socio-economic due to unsatisfactory
environmental conditions, poor personal hygiene, poor
quality and insufficient water supplies, unhygienic
preparation storage and feeding of foods. 5'6,7'8'9Since
personal hygiene and environmental sanitation are of
utmost importance in the prevention of diarrhea, health
education in food safety must receive high priority. For
this reason education of caretakers particularly mothers in
the principles of food safety should be considered as an
important intervention in prevention of diarrhoeal
diseases in young children. Education by the health
workers, from the c o m m u n i t y (such as Anganwadi
workers) can play a vital role in this preventive aspects, as
they make regular and frequent home visits that help
them to establish close links with mothers, thus enhancing
prospects for maternal and child health. Therefore, in
order to reduce the diarrheal morbidity and mortality in
children the present study was undertaken in which
training of AWW was done on food safety who in turn
Correspondence and Reprint requests : Dr. MiniSheth,Department
of Foods and Nutrition, Facultyof Home Science, The Maharaja
SayajiraoUniversityof Baroda,Vadodara-390 002,Gujarat,India
METHODS AND MATERIALS
Selection of Subjects : Eight Anganwadi centers were
randomly selected from the urban slums of Baroda. From
these, 200 households (25 under each Anganwadi worker
working in the ICDS set up), were purposively selected
with children in the age group of 6-24 months.
Baseline Survey: The baseline data of all the 200
households were collected with respect to their
socioeconomic status, diarrhea profile of the children,
knowledge attitudes and practices of mothers (KAP)
regarding child feeding practices and microbial detection
of hand rinse samples of both mothers and children.
Diarrhea Profile : At the time of interview, mothers
were asked regarding the episodes of diarrhea that the
child underwent and their severity in the past one month.
The WHO definition of diarrhea as well as the criteria of
judging the severity of diarrhea obtained from the
Pediatric Department of Sir Sayajirao Gaekwad Hospital
of Baroda, was considered as tool for establishing the
diarrhea profile. According to this, children having
diarrhea were categorized into those having mild (3-4
loose watery stools in 24 hours), moderate (5-6 loose
watery stools) and severe (more than 6 loose watery stools
which resulted in signs of dehydration and required
medical attention).
Knowledge Attitudes and Practices (KAP) :
Information on KAP was collected with respect to
mothers's knowledge on 'What Causes Diarrhea', child

Indian Journal of Pediatrics, Volume 71--October, 2004 879

 Mini Sheth and Monika Obrah
feeding practices with an emphasis on hand washing
practices, environmental sanitation and personal hygiene
using a pretested structured questionnaire and spot
observations.
Determination of Enterococci in Hand Rinse Samples
of Mothers and Children : Presence of enterococci in the
hand rinse samples of 50 mothers and 50 children was
done using the 'Hi media' rapid enterococci test kit. The
mothers and children were asked to rinse their hands into
a broad mouth funnel with sterile water into sterile bottles
containing the test medium. The change in color from
yellow to dark green indicated the presence of
enterococci.
Training of the AWW: Food safety education was
imparted to 8 Anganwadi workers in two sessions using
calendars and pamphlets, role play and charts
encompassing the key messages of causes of diarrhoea,
washing hands, keeping the households and
surroundings clean and not to feed the leftovers foods
stored at ambient temperatures to children. Food safety
material (calendars and leaflets) was distributed to them
to be further distributed to the mothers at the time of
home visits. It was ensured that the Anganwadi workers
educated each mother regarding safe feeding practices
and the consequences of severe diarrhea. Post
intervention data was collected after a period of two
months from the households as per the baseline.
Statistical Analysis: To the data on spot observations,
scores were assigned to the practices of personal hygiene
and environmental sanitation and were rated as excellent,
good, average and poor. The effect of intervention was
determined using Chi-square test. The effect of
intervention on KAP of mothers regarding their
knowledge on: causes of diarrhea, safe feeding practices,
personal hygiene and environmental sanitation was
studied using Student's t-test. In order to study the
impact of intervention on diarrhea profile, percentage of
children having diarrhea in varying degree of severity
was calculated and compared.
RESULTS
The results of the household survey are presented in
terms of socioeconomic status o~the families. These are
diarrhea profile of the children, environmental sanitation,
personal hygiene of the mothers, microbial analysis of
hand rinse of mothers and children and the KAP of the
mothers regarding child feeding practices, personal
hygiene and environmental sanitation.
Socioeconomic Status
Most of the families were nuclear and 59% children
belonged to the family size of 4-6. The literacy rate among
both mothers (85%) as well as fathers (95%) was found to
be high. In most of the families the monthly income
ranged from Rs.1000/- to Rs.1500/- indicating that they
belonged to low-income group. A majority of the
880
households were non-vegetarians. Large number of
families tapped water in their homes from municipal
source. Individual toilet facilities were available in 59% of
the households and as high as 40% of them either used
public toilets or defecated in open.
Diarrhea Profile of Children
As seen in Fig. 1, about 92% children suffered from one or
more episodes of diarrhea in the recent past at the
baseline. Of these 24%, 65% and 11% suffered from
severe, moderate and mild cases of diarrhea respectively.
After the food safety education intervention (FSEI), the
number of children suffering from diarrhea was reduced
to 39.5% from the baseline of 92%. And the severity of
diarrhea decreased from 24% at baseline to 19% after
FSEI. The total reduction in the incidence of diarrhea was
52%.
1"~'~ [
r
c-
O
V f~
Pre- Post-
intervention intervention
[!~Severe ==Moderate[] Mild [] No DiarrhoeaJ
Fig. 1. Diarrhoeaprofile of children (6-24 months) beforeand after
food safetyeducationintervention
Environmental Sanitation and Personal Hygiene
As seen in Table 1, before the FSEI, most of the
households (50.5%) had poor ratings for environmental
sanitation (ES), however, after the intervention the ES
scores of 55% of the subjects were excellent and only 14%
had poor scores. This improvement in the ES scores was
found to be statistically significant (p<0.001). The aspects
considered for excellent ES were absence of pool water
and open defecation inside and outside the house,
presence of covered dustbin outside the house, absence of
flies inside and outside the house and general cleanliness
of the house.
The personal hygiene (PH) rating for the mothers at
the baseline were poor (38.5%) to average (30.5%).
However, after the FSEI, the PH rating was excellent for
most of the mothers and only 8% had poor rating. This
improvement in the PH scores after FSEI was found to be
statistically significant (p<0.001). The aspects looked for
PH of the mothers were general appearance, clean nail,
hair neatly combed and her hand washing practices.
Indian Journal of Pediatrics, Volume 71---October, 2004
 Diarrhoea Prevention Through Food Safety Education

TABLE1. Scores and Ratings of Environmental Sanitation of 100

Households and Personal Hygiene of Mothers Before
and After Food Safety Education Intervention.
O
Score/Ratings PRE POST Chi Square Test
(N=200) (N=200) 8
Excellent 23 110
8
(18-20) (11.5) (55.0)
Z
Good 43 44
(16-17) (21.5) (22.0)
Z
Average 33 18 102.643"** _o
(14-15) (16.5) (9.0)
Poor 101 28 b-
W
(<4) (50.5) (14.0)
#
Personal Hygiene Ratings

Excellent 26 104 (HR) MOTHERS (HR) CHILDREN

(18-20) (13.0) (52.0) []PRE-INTERVENTIN [] POST-INTERVENTION
Good 36 66 125.088"** Fig. 2. Presence of enterococci in hand rinse (hr) samples of mothers
(16-17) (18.0) (33.0) and children before and after food safety education
intervention
Average 61 14
(14-15) (30.5) (7.0)
Poor 77 16 46% b e c a m e a w a r e t h a t f e e d i n g c o o k e d m o i s t l e f t o v e r
(<4) (30.5) (8) f o o d s s t o r e d at a m b i e n t t e m p e r a t u r e s for m o r e t h a n 8
h o u r s is a c a u s a t i v e factor for d i a r r h e a in children.
***Significant at p< 0.001
Numbers in parenthesis indicate percentage KAP of Mothers Regarding Environmental S a n i t a t i o n
A large p r o p o r t i o n (96.5%) of the m o t h e r s b e c a m e a w a r e
Detection of Enterococci in Hand Rinse Samples of t h e a s s o c i a t i o n of c h i l d ' s h e a l t h w i t h e n v i r o n m e n t .
A s seen in Fig. 2, p r i o r to FSEI, presence of enterococci w a s A l s o , m o s t of t h e h o u s e h o l d s (76.5%) s t a r t e d u s i n g a
d e t e c t e d in 90% of the h a n d rinse s a m p l e s of m o t h e r s a n d d u s t b i n for h o u s e h o l d waste d i s p o s a l as c o m p a r e d to only
in all the s a m p l e s collected f r o m children. H o w e v e r after 6% h o u s e h o l d s p r i o r to FSEI.
the intervention, the enterococci d e c r e a s e d to 25% a n d 90% KAP Mothers Regarding Personal Hygiene
in m o t h e r s a n d c h i l d r e n respectively.
M o s t of t h e m o t h e r s b e c a m e a w a r e o f t h e r e a s o n s for
K A P of Mothers Regarding the Etiology of Diarrhea, ES w a s h i n g h a n d s p r i o r to feeding, c o o k i n g a n d eating. 51%
and P H
s t a r t e d b e l i e v i n g t h a t it is n e c e s s a r y to w a s h h a n d s to
T h e r e w a s a n i m p r o v e m e n t in t h e p e r c e p t i o n s of t h e avoid diseases and microorganisms. Spot observations
m o t h e r s r e g a r d i n g diarrhoea, after FSEI (Table 2). M o s t of r e v e a l e d that m o s t of the m o t h e r s s t a r t e d w a s h i n g h a n d s
t h e m o t h e r s b e c a m e a w a r e of t h e v a r i o u s e t i o l o g i c a l w i t h s o a p a n d w a t e r after activities s u c h as visit to toilot,
f a c t o r s f o r d i a r r h e a . 90% o f t h e m a t t r i b u t e d n o t to cleaning child's defections, cleaning child's nose and
w a s h i n g h a n d s as a c a u s e of d i a r r h e a in c h i l d r e n . A l s o sweeping and mopping.

TABLE2. Knowledge, Attitudes and Practices (KAP) of Mothers with Regard to Diarrhea, Environmental Sanitation, Personal Hygiene and
Feeding Practices, Before and After Food Safety Education Intervention

Statistical KAP on KAP on Enviro- KAP on Personal KAP on Feeding Total KAP
Parameter Diarrhea mental Sanitation Hygiene Practices Scores

N Pre 200 Post 200 Pre 200 Post 200 Pre 200 Post 200 Pre 200 Post 200 Pre 200 Post 200

Mean 1.13 2.98 1.51 2.11 11.55 13.17 1.20 2.79 15.4 21.66
Standard Deviation + 0.829 _+1.06 _+0.91 + 0.44 -4-1.97 _+2.36 _+0.81 + 1.87 + 2.57 -+3.39
Standard Error 0.06 0.07 0.06 0.03 0.13 0.16 0.06 0.09 0.19 0.24
Level of significance *** *** *** *** *** *** *** *** *** ***
t-value 19.50 10.49 9.93 15.97 20.69
***Significant at p<0.001
Note : For KAP, each correct response was given a score of 2 and each wrong response was given a score of 1.

Indian Journal of Pediatrics, Volume 71--October, 2004 881

 Mini Sheth and Monika Obrah
KAP of Mothers Regarding Feeding Leftover Food to
Children
After the FSEI, m o s t of the m o t h e r (82.5%) either the
leftover food thoroughly as compared to only 13% before
intervention. M a n y mothers (50%) became aware of ill
effects of feeding leftover moist foods to the children
especially if that was stored at ambient temperature for
long hours.
DISCUSSION
The success of the present study can be attributed to the
cumulative effect of improvement in all the factors such
as ES, PH and feeding practices of the mothers. The key
messages imparted by the A W W during their home visits
could be comprehended more effectively by the mothers
because of their high literacy rate reported to be quite low
in earlier studies. Positive correlation between literacy
rate and the knowledge gains has also been reported in
some other studies. 1~
Poor environmental sanitation and personal hygiene of
mothers continues to be the leading etiological factor for
diarrhea. Behaviors such as child defecation on the floor,
w a t e r or r a g b e i n g u s e d to cleanse the child after
defecation and mother not washing the child's hand or
her h a n d s w i t h s o a p a n d w a t e r after d e f e c a t i o n or
cleansing child's perineum were directly related to high
incidence of diarrhea2 ~
The c h a n g e a g e n t s selected f r o m the c o m m u n i t y
f o r m e d an effective m e d i u m of c o m m u n i c a t i o n in the
education process. Generally the education strategies
o f t e n fail b e c a u s e the p r a c t i c e s are selected b y the
outsiders and proposed to the community22 The vitality
of health workers p l a y e d an important role here, as it
inspired them the confidence in them to become agents
for change. 13
Similar educational messages as in the present study
were directly imparted to the mothers in one of the earlier
studies. 16 However, the knowledge gains in the present
s t u d y a n d r e d u c t i o n in the incidence of d i a r r h e a in
c h i l d r e n (52%) is q u i t e r e m a r k a b l e w h i c h can be
attributed to the factor of introduction of change agents
(AWW) in the study. Many features of the AWW came up
in the study which include, a good rapport between them
and community, motivation, genuine interest in bringing
about the change, regular reinforcement and follow up of
the messages.
CONCLUSION
Food safety e d u c a t i o n i m p a r t e d t h r o u g h m o t i v a t e d
882
change agents can play an important role not only in the
reduction of diarrheal morbidities in y o u n g children but
increasing a w a r e n e s s in the m o t h e r s r e g a r d i n g Safe
Feeding Practices. Thus FSE should receive high priority
in the ongoing programmes for improving maternal and
child health.
REFERENCES
1. Malik KR. Ensuring food quality and food safety emerging
challenges. NFI Bull 1996;17: 5-8.
2. WorldHealth Organization. The World Health Report 1998 - Life
in 21 st Century : A Vision for All. WHO, 1998.
3. Sheth M, Sharma S, Patel S, Seshadri S. Hazard analysis and
critical control points of weaning foods fed o children in an
urban slum of Baroda. Indian J Pediatr 2000;67(6) : 405409.
4. Ahmed AAH, Moustafe MK, Marth EH. Incidence of Bacillus
cereus in milk and some milk products. J Food Prot 1983; 46 :
126.
5. Raymond Isley B. Primary health care, water supply and
sanitation in Africa. World Health Forum 1985;6 : 213-219.
6. Khan Hameed A. The sanitation gap. Development deadly
menace : Progress of Nations. UNICF Publications 1997;5-12.
7. Lal P, Bansal AK, Aggarwal CS, Taneja BK, Gogia V. Incidence
of diarrhea and some related environmental and behavioral
factors in Jhuggies of Delhi. Ind J Public Health 1996;40(2) : 35-
37.
8. Rowan N, Anderson JG, Anderton A. The bacteriological
quality of hospital prepared infants foods. J Hosp Infct 1997;
35(4) : 259-267.
9. UNICEF.The State of Worlds Children 2000. Progress report
2000. UNICEF,New Delhi.
10. Molbak K, Jensos H, Ingholthand Aaby P. Risk factors for
diarrhoeal disease, incidencein early childhood. A community
cohort from Guinea Bissan. Am J Epidemiology 1997; 146(3) :
279-281.
11. Khin-MaungU. Moy-KhinNyunt-Nyunt Wai, Nyi-win roam.
Thein-Thein-Myunt and Butler TC. Risk factors for persistent
diarrhea and malnutrition in Burmese children behavior
related to feeding and hand washing. J Trop Pediat 1994;40(1):
44-46.
12. Pinfold J. Importance of involving community members in
hygiene promotion. Health Dialogue 1996;4-6.
13. Aziz KM, Islam MS. Community participation in the
management of diarrhoeal .diseases. A review published by
International Center for Diarrheal Disease Research 1991;
Bangladesh.
14. Ali M, Sheikh R, Khalif M. Primary health care, female health
workers boost pmnary care. World Health Forum 1997;18 : 202-
209.
15. Lal Sandhadan SB. Impact of special nutritional programme
on nutrition and health status of children in urban slums of
Rohtak. Indian ] Pediatr 46(1) : 299-302.
16. Sheth M, Mehrotra S. Study of diarrhea profile of children (6
to 17 months) and the effectof imparting food safety education
on safe food practices of lower income group of mothers
residing in an urban slum of Baroda, M.Sc. thesis, Dept. of
Foods and Nutrition, M.S. University, 2000.
Indian Joumal of Pediatrics, Volume 71--October, 2004