Volume 101, Issue 2
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Despite being preventable, foodborne diseases remain a global health challenge. Poor food hygiene practices such as improper handling of kitchen utensils are among the major causes of diarrhea transmission. A formative study was conducted in Malawi to inform an intervention design to promote complementary food hygiene practices. An assessment of contextual and psychosocial factors for behavior change was conducted using Risk, Attitude, Norms, Ability, and Self-regulation model. We conducted 323 household surveys with caregivers of children aged 6 to 24 months. Analysis of variance was used to estimate difference between doers and non-doers of three targeted behaviors: washing utensils with soap, keeping utensils on a raised place, and handwashing with soap. Analysis of variance analyses revealed that literacy level, ownership of animals, and presence of handwashing facility and dish racks were contextual factors predicting storage of utensils on an elevated place and handwashing frequencies. Psychosocial factors, such as time spent to wash utensils with soap, distance to the handwashing facility, and cost for soap, had an influence on washing utensils and handwashing practices. Perceived vulnerability determined effective handwashing and storage of utensils. Perceived social norms and ability estimates were favorable for the three targeted behaviors. Promotion of already existing targeted beneficial behaviors should be encouraged among caregivers. Risk perceptions on storage of utensils and handwashing practices should be increased with motivational exercises such as paint games. Caregivers’ technical know-how of local dish rack and tippy tap construction is essential.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


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  1. World Health Organization, 2017. Key Facts About Diarrhoeal Diseases. Available at: http://www.who.int/mediacentre/factsheets/fs330/en/. Accessed January 19, 2017. [Google Scholar]
  2. Walker CLF, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, O’Brien KL, Campbell H, Black RE, , 2013. Global burden of childhood pneumonia and diarrhoea. Lancet 381: 14051416. [Google Scholar]
  3. World Health Organization, 2017. Fact Sheet About Food Safety. Available at: http://www.who.int/mediacentre/factsheets/fs399/en/. Accessed January 19, 2017. [Google Scholar]
  4. Motarjemi Y, Steffen R, Binder HJ, , 2012. Preventive strategy against infectious diarrhea—A holistic approach. Gastroenterology 143: 516519. [Google Scholar]
  5. Käferstein F, , 2003. Foodborne diseases in developing countries: Aetiology, epidemiology and strategies for prevention. Int J Environ Health Res 13(Suppl 1): S161S168. [Google Scholar]
  6. World Health Organization, 2005. WHO Estimates of Global Burden of Foodborne Diseases: Foodborne Disease Burden Epidemiology Reference Group 2007–2015. Geneva, Switzerland: WHO. [Google Scholar]
  7. Motarjemi Y, , 2000. Research priorities on safety of complementary feeding. Pediatrics 106: 13041305. [Google Scholar]
  8. Ehiri JE, Prowse JM, , 1999. Child health promotion in developing countries: the case for integration of environmental and social interventions? Health Policy Plan 14: 110. [Google Scholar]
  9. Ehiri JE, Azubuike MC, Ubbaonu CN, Anyanwu EC, Ibe KM, Ogbonna MO, , 2001. Critical control points of complementary food preparation and handling in eastern Nigeria. Bull World Health Organ 79: 423433. [Google Scholar]
  10. Oni GA, , 1996. Infant feeding practices, socio-economic conditions and diarrhoeal disease in a traditional area of urban Ilorin, Nigeria. East Afr Med J 73: 283288. [Google Scholar]
  11. Wardlaw T, Salama P, Brocklehurst C, Chopra M, Mason E, , 2010. Diarrhoea: why children are still dying and what can be done. Lancet 375: 870872. [Google Scholar]
  12. Michanie S, Bryan FL, Alvarez P, Olivo AB, , 1987. Critical control points for foods prepared in households in which babies had salmonellosis. Int J Food Microbiol 5: 337354. [Google Scholar]
  13. Steinbaum L, Njenga SM, Kihara J, Boehm AB, Davis J, Null C, Pickering AJ, , 2016. Soil-transmitted helminth eggs are present in soil at multiple locations within households in rural Kenya. PLoS One 11: e0157780. [Google Scholar]
  14. Bryan FL, Michanie S, Fernández NM, Vizcarra MM, Taboada PD, Navarro SO, Alonso AB, Requejo EG, , 1988. Hazard analyses of foods prepared by migrants living in a new settlement at the out-skirts of Lima, Peru. J Food Prot 51: 314323. [Google Scholar]
  15. Gil AI, Lanata CF, Hartinger SM, Mäusezahl D, Padilla B, Ochoa TJ, Lozada M, Pineda I, Verastegui H, , 2013. Fecal contamination of food, water, hands, and kitchen utensils at the household level in rural areas of Peru. J Environ Health 76: 102106. [Google Scholar]
  16. Black RE, Lopez De Roma G, Brown KH, Bravo N, Grados Bazalar OG, Creed Kanashtro HC, , 1989. Incidence and etiology of infantile diarrhea and major routes of transmission in Huascar, Peru. Am J Epidemiol 129: 785799. [Google Scholar]
  17. Imong SM, Rungruengthanakit K, Ruangyuttikarn C, Wongsawasdii L, Jackson DA, Drewett RF, , 1989. The bacterial content of infant weaning foods and water in rural northern Thailand. J Trop Pediatr 35: 1418. [Google Scholar]
  18. Touré O, Coulibaly S, Arby A, Maiga F, Cairncross S, , 2011. Improving microbiological food safety in peri-urban Mali; an experimental study. Food Control 22: 15651572. [Google Scholar]
  19. Rahman MJ, Nizame FA, Nuruzzaman M, Akand F, Islam MA, Parvez SM, Stewart CP, Unicomb L, Luby SP, Winch PJ, , 2016. Toward a scalable and sustainable intervention for complementary food safety. Food Nutr Bull 37: 186201. [Google Scholar]
  20. Pang J, Chua SWJL, Hsu L, , 2015. Current knowledge, attitude and behaviour of hand and food hygiene in a developed residential community of Singapore: a cross-sectional survey. BMC Public Health 15: 577. [Google Scholar]
  21. Usfar AA, Iswarawanti DN, Davelyna D, Dillon D, , 2010. Food and personal hygiene perceptions and practices among caregivers whose children have diarrhea: a qualitative study of urban mothers in Tangerang, Indonesia. J Nutr Educ Behav 42: 3340. [Google Scholar]
  22. Penakalapati G, Swarthout J, Delahoy MJ, McAliley L, Wodnik B, Levy K, Freeman MC, , 2017. Exposure to animal feces and human health: a systematic review and proposed research priorities. Environ Sci Technol 51: 1153711552. [Google Scholar]
  23. Headey D, Nguyen P, Kim S, Rawat R, Ruel M, Menon P, , 2017. Is exposure to animal feces harmful to child nutrition and health outcomes? A multicountry observational analysis. Am J Trop Med Hyg 96: 961969. [Google Scholar]
  24. Taulo S, Wetlesen A, Abrahamsen RK, Narvhus JA, Mkakosya R, , 2009. Quantification and variability of Escherichia coli and Staphylococcus aureus cross-contamination during serving and consumption of cooked thick porridge in Lungwena rural households, Malawi. Food Control 20: 11581166. [Google Scholar]
  25. Taulo S, Wetlesen A, Abrahamsen R, Kululanga G, Mkakosya R, Grimason A, , 2008. Microbiological hazard identification and exposure assessment of food prepared and served in rural households of Lungwena, Malawi. Int J Food Microbiol 125: 111116. [Google Scholar]
  26. Ejemot-Nwadiaro RI, Ehiri JE, Arikpo D, Meremikwu MM, Critchley JA, , 2015. Hand washing promotion for preventing diarrhoea. Cochrane Database Syst Rev 195. [Google Scholar]
  27. Curtis V, Cairncross S, , 2003. Effect of washing hands with soap on diarrhoea risk in the community: a systematic review. Lancet Infect Dis 3: 275281. [Google Scholar]
  28. Monte CM, Ashworth A, Nations MK, Lima AA, Barreto A, Huttly SR, , 1997. Designing educational messages to improve weaning food hygiene practices of families living in poverty. Soc Sci Med 44: 14531464. [Google Scholar]
  29. Luby SP, Halder AK, Huda T, Unicomb L, Johnston RB, , 2011. The effect of handwashing at recommended times with water alone and with soap on child diarrhea in rural Bangladesh: an observational study. PLoS Med 8: e1001052. [Google Scholar]
  30. Huber AC, Mosler H-J, , 2013. Determining behavioral factors for interventions to increase safe water consumption: a cross-sectional field study in rural Ethiopia. Int J Environ Health Res 23: 96107. [Google Scholar]
  31. Oxford Dictionaries, nd. Psychosocial | Definition of psychosocial in English. Oxford Dictionaries. Available at: https://en.oxforddictionaries.com/definition/psychosocial. Accessed January 28, 2019.
  32. Slekiene J, Mosler HJ, , 2018. Characterizing the last latrine nonowners in rural Malawi. Am J Trop Med Hyg 98: 295299. [Google Scholar]
  33. Mosler HJ, , 2012. A systematic approach to behavior change interventions for the water and sanitation sector in developing countries: a conceptual model, a review, and a guideline. Int J Environ Health Res 22: 431449. [Google Scholar]
  34. Rosenstock IM, , 1974. Historical origins of the health belief model. Health Educ Behav 2: 328335. [Google Scholar]
  35. Fishbein M, Ajzen I, , 2010. Predicting and Changing Behaviour: The Reasoned Action Approach. New York, NY: Psychology Press. [Google Scholar]
  36. Lilje J, Kessely H, Mosler HJ, , 2015. Factors determining water treatment behavior for the prevention of cholera in Chad. Am J Trop Med Hyg 93: 5765. [Google Scholar]
  37. Friedrich MN, Binkert ME, Mosler HJ, , 2017. Contextual and psychosocial determinants of effective handwashing technique: recommendations for interventions from a case study in Harare, Zimbabwe. Am J Trop Med Hyg 96: 430436. [Google Scholar]
  38. Mosler H, Contzen N, , 2016. Systematic Behavior Change in Water, Sanitation and Hygiene. A Practical Guide Using the RANAS Approach. Dubendorf, Switzerland: Eawag. [Google Scholar]
  39. Government of Malawi, 2018. Malawi 2018 Census Preliminary Report. Zomba, Malawi: National Statistical Office. [Google Scholar]
  40. Climate Data Organization, 2018. Climate: Chikwawa. Available at: https://en.climate-data.org/location/27968/. Accessed May 31, 2018. [Google Scholar]
  41. Government of Malawi, 2014. Malawi 2013-14 MDG Endline Survey Final Report—UNICEF MICS. Available at http://mics.unicef.org/news_entries/13. Accessed February 1, 2019. [Google Scholar]
  42. Bandura A, , 1982. Self-efficacy mechanism in human agency. Am Psychol 37: 122147. [Google Scholar]
  43. Rasheed S, Haider R, Hassan N, Pachón H, Islam S, Jalal CS, Sanghvi TG, , 2011. Why does nutrition deteriorate rapidly among children under 2 years of age? Using qualitative methods to understand community perspectives on complementary feeding practices in Bangladesh. Food Nutr Bull 32: 192200. [Google Scholar]
  44. Kung’u JK, Boor KJ, Ame SM, Ali NS, Jackson AE, Stoltzfus RJ, , 2009. Bacterial populations in complementary foods and drinking-water in households with children aged 10–15 months in Zanzibar, Tanzania. J Health Popul Nutr 27: 4152. [Google Scholar]
  45. Flax VL, Phuka J, Cheung YB, Ashorn U, Maleta K, Ashorn P, , 2010. Feeding patterns and behaviors during home supplementation of underweight Malawian children with lipid-based nutrient supplements or corn-soy blend. Appetite 54: 504511. [Google Scholar]
  46. Seimetz E, Boyayo A-M, Mosler H-J, , 2016. The influence of contextual and psychosocial factors on handwashing. Am J Trop Med Hyg 94: 14071417. [Google Scholar]
  47. Contzen N, Meili IH, Mosler HJ, , 2015. Changing handwashing behaviour in southern Ethiopia: a longitudinal study on infrastructural and commitment interventions. Soc Sci Med 124: 103114. [Google Scholar]
  48. Scott BE, Lawson DW, Curtis V, , 2007. Hard to handle: understanding mothers’ handwashing behaviour in Ghana. Health Policy Plan 22: 216224. [Google Scholar]
  49. Gautam OP, Schmidt WP, Cairncross S, Cavill S, Curtis V, , 2017. Trial of a novel intervention to improve multiple food hygiene behaviors in Nepal. Am J Trop Med Hyg 96: 14151426. [Google Scholar]
  50. Waterkeyn J, Cairncross S, , 2005. Creating demand for sanitation and hygiene through Community Health Clubs: a cost-effective intervention in two districts in Zimbabwe. Soc Sci Med 61: 19581970. [Google Scholar]
  51. Colbourn T, 2015. Cost-effectiveness and affordability of community mobilisation through women’s groups and quality improvement in health facilities (MaiKhanda trial) in Malawi. Cost Eff Resour Alloc 13: 1. [Google Scholar]
  52. Hygienic solutions, 2019. Glo Germ: Handwashing training. Available at: http://www.glogerm.com/handwashing.html. Accessed January 28, 2019.
  53. Grimason AM, Masangwi SJ, Morse TD, Jabu GC, Beattie TK, Taulo SE, Lungu K, , 2014. Knowledge, awareness and practice of the importance of hand-washing amongst children attending state run primary schools in rural Malawi. Int J Environ Health Res 24: 3143. [Google Scholar]
  54. Biran A, Schmidt WP, Varadharajan KS, Rajaraman D, Kumar R, Greenland K, Gopalan B, Aunger R, Curtis V, , 2014. Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trial. Lancet Glob Health 2: e145e154. [Google Scholar]
  55. Boyce JM, Havill NL, Dumigan DG, Golebiewski M, Balogun O, Rizvani R, , 2009. Monitoring the effectiveness of hospital cleaning practices by use of an adenosine triphosphate bioluminescence assay. Infect Control Hosp Epidemiol 30: 678684. [Google Scholar]

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  • Received : 03 Aug 2018
  • Accepted : 25 Apr 2019
  • Published online : 24 Jun 2019

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