Design, delivery, and determinants of uptake: findings from a food hygiene behavior change intervention in rural Bangladesh

Abstract

Background: Microbial food contamination, although a known contributor to diarrheal disease and highly prevalent in low-income settings, has received relatively little attention in nutrition programs. Therefore, to address the critical pathway from food contamination to infection to child undernutrition, we adapted and integrated an innovative food hygiene intervention into a large-scale nutrition-sensitive agriculture trial in rural Bangladesh. In this article, we describe the intervention, analyze participation and uptake of the promoted food hygiene behaviors among intervention households, and examine the underlying determinants of behavior adoption.

Methods: The food hygiene intervention employed emotional drivers, engaging group activities, and household visits to improve six feeding and food hygiene behaviors. The program centered on an 'ideal family' competition. Households' attendance in each food hygiene session was documented. Uptake of promoted behaviors was assessed by project staff on seven 'ideal family' indicators using direct observations of practices and spot checks of household hygiene conditions during household visits. We used descriptive analysis and mixed-effect logistic regression to examine changes in household food hygiene practices and to identify determinants of uptake.

Results: Participation in the food hygiene intervention was high with more than 75% attendance at each session. Hygiene behavior practices increased from pre-intervention with success varying by behavior. Safe storage and fresh preparation or reheating of leftover foods were frequently practiced, while handwashing and cleaning of utensils was practiced by fewer participants. In total, 496 of 1275 participating households (39%) adopted at least 5 of 7 selected practices in all three assessment rounds and were awarded 'ideal family' titles at the end of the intervention. Being an 'ideal family' winner was associated with high participation in intervention activities [adjusted odds ratio (AOR): 11.4, 95% CI: 5.2-24.9], highest household wealth [AOR: 2.3, 95% CI: 1.4-3.6] and secondary education of participating women [AOR: 2.2, 95% CI: 1.4-3.4].

Conclusion: This intervention is an example of successful integration of a behavior change food hygiene component into an existing large-scale trial and achieved satisfactory coverage. Future analysis will show if the intervention was able to sustain improved behaviors over time and decrease food contamination and infection.

Keywords: Behavior adoption; Child feeding; Emotional driver; Implementation.

Fig. 1

Design and implementation of the food hygiene intervention within the FAARM trial in Bangladesh

Fig. 2

Pictures of communication materials and key food hygiene activities

Fig. 3

Practice of key behaviors composing the ‘ideal family’ and ‘clean kitchen’ indicators. a ‘Ideal family’ indicators. b ‘Clean kitchen’ indicators. Practice of ‘ideal family’ and ‘clean kitchen’ behaviors (in % of households) were assessed over three observation rounds, ranging from never practiced (lightest grey) to always practiced (darkest grey). This graph only shows households that could be observed for ‘ideal family’ and ‘clean kitchen’ indicators during all three observation rounds (n = 1022), households with less than 3 observation rounds were excluded (missing values: 253)