8/8/2019 Seth 2004

1/4

D i a r r h e a P r e v e n t i o n T h r o u g h F o o d S a f e t y E d u c a t i o nM i n i S h e t h a n d M o n i k a O b r a hDep a r tmen t of Foods and Nu trition , M.S. U nivers ity of Baroda, Vadodara, Gujara t, India.

A b s t r a c t . O b j e c t i v e : Food s a f e t y e duc a t i on ( FS E ) w a s imparted in order to reduce the prevalence of diarrhea in childrenand improv ing the knowledge , attitude an d pract ices of mothers regarding sa fe feeding prac t ices . M e t h o d s : T h e s tu d y w a sconducted on mothers (n=200) of underpr iv i leged children ( 6-24 months) through A n g a n w a d i workers (AWW ). The food safetyeducat ion package incorpora ted three messages: washing hands with soap and water, avoid feeding leftover food and k e e psurrounding c lean. Th ese w ere imp arted us ing lec tures , s logans , posters , charts, flash cards, role-play. Calendars and leaf letsw e r e a ls o h a n d e d o v e r to t h e mothers as education material. After food sa fe ty education intervention, the hous e ho l ds w e res t ud ie d a ga i n a s a t t he ba s e l i ne , on various aspects . R e s u l t : The re w a s 5 2 % re duc t i on i n t he i nc i de nc e o f d i a r rhe a . Theenvironmental sanitation and personal hygiene scores of most of the househo lds and m others improved. Imp rovement in thepra c ti ce o f ha nd- w a s h i ng a nd a v o i da nc e o f f e ed i ng leftovers to children w a s s e e n . T h e r e w a s reduction in the microbial loadi n t he ha n d r i ns e s a m pl e s o f bo t h mothers and chi ldren. C o n c l u s i o n : A W W prov e d t o be e ff e ct iv e c ha n ge a ge nt s and FSEwas successful in br inging abo ut a pos i t ive behav ior modi f ica tion in mothers . [ In dia n J P ed ia t r 200 4; 71 (10 ) : 879 -88 2]E-ma i l : m kss 7 @ho tma il .comK e y w o r d s : F o o d safe ty ; D iarrhea; Ch i ld ren; B eha v ior mo di f ica t ion ; Mothers ; Educat ion .Diarrhea continues to plague the developing world,resulting in more than 3 million deaths. Childrenespecially those who are malnourished remain at a greaterrisk. More than 1.5 billion episodes of diarrhea have beenreported in the children below 5 years resulting in over 3mill ion death s. 1,2 Besides, con tam ina ted water,contamination of food also play an important role in theetiology of diarrhea. 3,4 The chances of food contaminationand cross contamination, become higher especially in thelower socio-economic due to unsatisfactoryenvironmental conditions, poor personal hygiene, poorquality and insufficient water supplies, unhygienicpr ep ar at io n storage an d feeding of foods. 5'6,7'8'9 Sincepersonal hygiene and environmental sanitation are ofutmost importance in the prevention of diarrhea, healtheducat ion in food sa fety must receive high priority. Forthis reason education of caretakers particularly mothers inthe principles of food safety should be considered as animportant intervention in prevention of diarrhoealdiseases in young children. Education by the healthworkers, from the community (such as A n g a n w a d iworkers) can p lay a vital role in this preventive aspects, asthey make regu lar and frequent home visits that helpthem to establish close links with mothers, thus enhancingprospects for mat ernal an d child health. Therefore, inorder to reduce the diarrheal morbidity and mortality inchildren the present study was undertaken in whichtraining of AWW was done on food safety who in turnCorrespondence and Reprint requests : Dr. Mini Sheth, Departmentof Foods and Nutrition, Faculty of Home Science, The MaharajaSayajiraoUniversityof Baroda, Vadodara -390 002, Gujarat, India

educated the mothers.M E T H O D S A N D M A T E R I A L S

Select ion o f Subjects : Eight Anganwadi centers wererandomly selected from the urban slums of Baroda. Fromthese, 200 households (25 und er each Anganwadi workerworki ng in the ICDS set up), were purposively selectedwith children in the age group of 6-24 months.B a s e l i n e S u r v e y : The baseline data of all the 200households were collected with respect to theirsocioeconomic status, d iarrhea profile of the children,knowledge attitudes and practices of mothers (KAP)regarding child feeding practices and microbial detectionof hand rinse samples of both mothers and children.Diarrhea Pro f i le : A t the time of interview, motherswere asked regarding the episodes of diarrhea that thechild underwen t and their severity in the past one month.The WHO definit ion of diarrhea as well as the criteria ofjudging the severity of diarrhea obtained from thePediatric Depar tment of Sir Sayajirao Gaekwad Hospitalof Baroda, was co nsidered as tool for establishing thediarrhea profile. According to this, children havingdiarrhea were categorized into those having mild (3-4loose water y stools in 24 hours), m oder ate (5-6 loosewatery stools) and severe (more than 6 loose watery stoolswhich resulted in signs of dehyd ratio n and requ iredmedical attention).K n o w l e d g e A t t i tu d e s a n d P r a c t i c e s ( K A P ) :Information on KAP was collected with respect tomothers's knowledge on 'What Causes Diarrhea', child

Indian Journa l of Pedia t r ics , Volume 71--O ctober, 2004 879

8/8/2019 Seth 2004

2/4

M i n i S h e t h a n d M o n i k a O b r a hfeeding practices with an emphasis on hand washingpractices, environmental sanitation and personal hygieneusing a pretested structured questionnaire and spotobservations.Determination of Enterococci in Hand Rinse Sampleso f Mo thers a nd Children : Presence of enterococci in thehand rinse samples of 50 mothers and 50 children wasdone using the 'Hi med ia' rapid enterococci test kit. Themothers and children were asked to rinse their hands intoa broad mou th funnel with sterile water into sterile bottlescontaining the test mediu m. The change in color fromyellow to dark green indicated the presence ofenterococci.T r a in i ng o f t he A W W : Food safety education wasimparted to 8 Anganwadi workers in two sessions usingcalendars and pamphlets, role play and chartsencompass ing the key messages of causes of diarrhoea,washing hands, keeping the households andsurro unding s clean and not to feed the leftovers foodsstored at ambien t temperatures to children. Food safetymaterial (calendars and leaflets) was distributed to themto be further distributed to the mothers at the time ofhome visits. It was ensured that the Anganwadi workerseducated each mother regarding safe feeding practicesand the consequences of severe diarrhea. Postintervention data was collected after a period of twomonth s from the households as per the baseline.Statistical Analysis: To the data on spot observations,scores were assigned to the practices of personal hygieneand environmental sanitation and were rated as excellent,good, average a nd poor. The effect of intervention wasdetermined using Chi-square test. The effect ofintervention on KAP of mothers regarding theirknowledge on: causes of diarrhea, safe feeding practices,personal hygi ene and environmental sanitation wasstudied using Student's t-test. In order to study theimpact of intervention on diarrhea profile, percentage ofchildren having diarrhea in varying degree of severitywas calculated and compared.

R E S U L T SThe results of the househol d survey are presented interms of socioeconomic status o~the families. These arediarrhea profile of the children, environmenta l sanitation,personal hygiene of the mothers, microbial analysis ofhand rinse of mothers and children and the KAP of themothers regarding child feeding practices, personalhygiene and environmental sanitation.S o c i o e c o n o m i c S ta tu sMost of the families were nuclear and 59% childrenbelonged to the family size of 4-6. The literacy rate amongboth mothers (85%) as well as fathers (95%) was found tobe high. In most of the families the mon thl y incomeranged from Rs.1000/- to Rs.1500/- indicating that theybelonged to low-income group. A majority of the

households were non-vegetarians. Large number offamilies tapped water in their homes from m u n i c i p a lsource. Individual toilet facilities were available in 59% ofthe households and as high as 40% of them either usedpublic toilets or defecated in open.Diarrhea Prof i l e o f Chi ldrenAs seen in Fig. 1, about 92% children suffered from one ormore episodes of diarrhea in the recent past at thebaseline. Of these 24%, 65% and 11% suffered fromsevere, modera te and mild cases of diarrhea respectively.After the food safety education intervent ion (FSEI), thenumber of children suffering from diarrhea was reducedto 39.5% from the baseline of 92%. And the severi ty ofdiarrhea decreased f rom 24% at baseline to 19% afterFSEI. The total reduct ion in the incidence of diarrhea was52%.

1 " ~ ' ~ [r

c -O

V f~ Pre- P o s t -i n t e r v e n t i o n i n t e r v e n t i o n[ !~ S e v e r e ==Moderate ] Mild [] No D i a r r h o e a J

Fig. 1. Diarrhoeaprofile of children (6-24 months) before and afterfood safetyeducation ntervention

E n v i r o n m e n ta l S a n i ta t i on a n d Pe r s o n a l H y g i e n eAs seen in Table 1, before the FSEI, most of thehouseholds (50.5%) had poor rat ings for environmentalsanitation (ES), however, after the in terventi on the ESscores of 55% of the subjects were excellent and only 14%had poor scores. This improvement in the ES scores wasfound to be statistically significant (p

8/8/2019 Seth 2004

3/4

Di a r rh o e a Pre v e n ti o n T h ro u g h F o o d Sa f e t y Ed u c a t io nTABLE 1. Scores and R at i ngs o f E nvi ronment a l Sani t a t i on o fHo useho lds and Personal Hygiene of Mothers Beforeand After Food S afety Education Intervention.Score/Ratings PRE POST Chi Square Test(N=200) (N=200)Exce llent 23 110(18-20) (11.5) (55.0)G ood 43 44(16-17) (21.5) (22.0)A verag e 33 18(14-15) (16.5) (9.0)Poor 101 28(

8/8/2019 Seth 2004

4/4

M i n i S h e th a n d M o n i k a O b r a h

K A P o f M o t h e r s R e g a r d i n g F e e d i n g L e f to v e r F o o d toC h i l d r e nAfter the FSEI, most of the mother (82.5%) either theleftover food thoro ughl y as comp ared to only 13% beforeintervention. Many mothers (50%) became aware of i l leffects of feeding leftover mo ist fo ods to the childrenespecially if that was stored at ambient temperature forlong hours.

D I S C U S S I O N

The success of the present stud y can be attributed to thecumulative effect of impr ove ment in all the factors suchas ES, PH and feeding practices of the mothers. The keymessages imparted b y the AWW d uring their home visitscould be comp rehe nde d more effectively by the mothersbecause of their high literacy rate reported to be quite lowin earlier studies. Positive correlation between literacyrate and the knowledge gains has also been reported insome other studies. 1~

Poor environmental sanitation and personal hygiene ofmothers continues to be the leading etiological factor fordiarrhea. Behaviors suc h as child defecation on the floor,water or rag being used to cleanse the chi ld af terdefecation and mo ther not washing the child's hand orher hands wi th soap and water a f t e r defeca t ion orcleansing child's perine um were directly related to highincidence of dia rrhea2 ~

The change agent s se l ec ted f rom the communi tyformed an effective medium of communication in theeducation process. Generally the education strategiesof ten fai l because the pract ices are selected by theoutsiders and propo sed to the community22 The vitalityof health worke rs pla yed an importa nt role here, as itinspired them the confidence in them to become agentsfor change. 13

Similar educational messag es as in the present stud ywere directly imparted to the mothers in one of the earlierstudies. 16 Howeve r, the know ledg e gains in the presentstudy and reduct ion in the incidence of diar rhea inchi ldren (52%) i s qui t e r emarkable which can beattributed to the factor of introductio n of change agents(AWW) in the study. Ma ny features of the AWW came upin the study which include, a good rapp ort between themand commun ity, motivation, genuine interest in bringingabout the change, regular reinforcement and follow up ofthe messages.

C O N C L U S I O NFood safe ty educat ion impar t ed through mot iva ted

change agents can play an important role not only in thereduction of diarrheal morbidities in you ng children butincreasing awareness in the mothers regarding SafeFeeding Practices. Thus FSE should receive high pr iorityin the ongoing programmes for improving maternal andchild health.

R E F E R E N C E S1. Malik KR. Ensuring food quality and food safety emergingchallenges. NF I Bu ll 1996; 17: 5-8.2. WorldHealth Organization. TheWorld Health Report 1998 - Life

in 21 st Cen tury : A Vision for All . WHO, 1998.3. Sheth M, Sharma S, Patel S, Seshadri S. Hazard analysis andcritical control points of weaning foods fed o children in anurban slum of Baroda.Indian J Pediatr 2000; 67(6) : 405409.4. Ahmed AAH, Moustafe MK, Marth EH. Incidence of Bacilluscereus in milk and some milk products. J Food Prot 1983; 46 :126.5. Raymond Isley B. Primary health care, water supply andsanitation in Africa. World Health Forum 1985; 6 : 213-219.6. Khan Hameed A. The sanitation gap. Development deadlymenace : Progress of Nations. UNICF Publications 1997;5-12.7. Lal P, Bansal AK, Aggarwal CS, Taneja BK, Gogia V. Incidenceof diarrhea and some related environmental and behavioralfactors in Jhuggies of Delhi. Ind J Public Health 1996; 40(2) : 35-37.8. Rowan N, Anderson JG, Anderton A. The bacteriologicalquality of hospital prepared infants foods. J Hosp In fc t 1997;35(4) : 259-267.9. UNICEF.The State of Worlds Children 2000. Progress report2000. UNICEF, New Delhi.10. Molbak K, Jensos H, Ingholthand Aaby P. Risk factors fordiarrhoeal disease, incidence n early childhood. A communitycohort from Guinea Bissan. Am J Epidemiology 1997; 146(3) :279-281.11. Khin-Maung U. Moy-KhinNyunt-Nyunt Wai, Nyi-win roam.Thein-Thein-Myunt and Butler TC. Risk factors for persistentdiarrhea and malnutri tion in Burmese children behaviorrelated to feeding and hand washing. J Trop Pediat 1994; 40(1):44-46.12. Pinfold J. Importance of involving community members inhygiene promotion. Health Dialogue 1996; 4-6.13. Aziz KM, Islam MS. Comm unity participation in themanagement of diarrhoeal .diseases. A review published byInternational Center for Diarrheal Disease Research 1991;Bangladesh.14. Ali M, Sheikh R, Khalif M. Primary health care, female healthworkers boost pmnary care. World Health Forum 1997; 18 : 202-209.15. Lal Sandhadan SB. Impact of special nutritional programmeon nutrition and health status of children in urban slums ofRohtak. Indian ] Pediatr 46(1) : 299-302.16. Sheth M, Mehrotra S. Study of diarrhea profile of children (6to 17 months) and the effect of imparting food safety educationon safe food practices of lower income group of mothersresiding in an urban slum of Baroda, M.Sc. thesis, Dept. ofFoods and Nutrition, M.S. University, 2000.

882 Indian Joum a l o f Ped ia t ri cs , Vo lum e 71 - -Oc tobe r , 2004