The authors have declared that no competing interests exist.
Foodborne diseases are a major public health problem which predominantly affects infants and young children. Appropriate complementary food hygiene practice is very important to reduce the prevalence of foodborne illnesses. However, the information regarding this practice is not available and assessed before. Thus, the study was aimed to assess complementary food hygiene practices among mothers of children aged 6-23 months.
A community based cross-sectional study was conducted in Robe town on a samples of 517 mother-child pairs, which were selected by using systematic sampling technique. Data was collected using pre-tested and structured questionnaire, and each variable was described in the frequency and percentage. Bivariable and multivariable logistic regression analyses were used to identify factors associated with complementary food hygiene practice. Odds ratios with 95% confidence interval were used to assess levels of significance.
The result indicated that 55% of participated mothers scored above the mean score of food hygiene practices. Mothers of children aged 12-23 months had higher odds to practice good food hygiene measures than those of aged 6-11 months (AOR, 1.82 95% CI (1.21, 2.73)). Mothers whose children attended growth monitoring session practice good food hygiene than their counterpart (AOR, 2.74 95% CI (1.49, 5.06)). Mothers having media exposure, and having knowledge on critical times of hand washing had relatively good food hygiene measures (AOR, 0.73 95 CI (1.14, 2.62)). Among food hygiene measures; handwashing with water and soap were low before eating food (17%), before feeding children (21%) and before preparing food (32%) when compared with after visiting the toilet (81%) and touching dirt (68%).
The study identified that food hygiene practices in the current study were mainly associated with child age, growth monitoring follow-up, maternal awareness about critical times of hand washing, and media exposure. So, improving knowledge of mothers on critical times of handwashing, strengthening growth monitoring follow-up and media promotion are important measures to improve food hygiene practices among mothers of infants and young children.
Food hygiene is the conditions and measures necessary to ensure the safety of food from production to consumption. Food can become contaminated at any point during slaughtering or harvesting, processing, storage, distribution, transportation and preparation
The period of complementary feeding, which covers a child from 6-23 months of age, is a very vulnerable period when under nutrition starts in many infants, contributing to the high prevalence of undernutrition in children under two years of age
Foodborne disease is a problem in both developing and developed countries
International consultations among professionals identified hand washing with soap and water as a top priority in all settings
World Health Organization (WHO) recommends keeping clean all food contact surfaces and equipment used in food preparation
A community based cross-sectional study was conducted from March to April 2017 in Robe town, Southeast Ethiopia. The source populations of the study were all mothers of infants and young children aged 6-23 months who live in the town. The study population was all sampled mothers of children aged 6-23 months. Mothers who are permanent residents (resides in the town at least for 6 months) and have infants or young children aged 6-23 months were included in the study.
The sample size was determined by using Epi Info version 7 statistical sample size calculator for a population survey. The systematic sampling technique was employed to select the study participants. Data were collected using an interviewer-administered and structured questionnaire. The data collection tools regarding the various socio-demographic and environmental variables were adopted from Ethiopian Demographic and Health Survey (EDHS) questionnaire with some modification to fit with the context
The data were collected using pre-coded questions that relate to food hygiene practices by interviewing the mothers and questions on data of household sanitation facilities like latrine type was accompanied with observation. Data were collected by six personnel, one degree, and five diploma nurses. Data collectors were supervised by two public health professionals. Supervisors and data collectors were trained in the overall introduction of the study process. During data collection, the supervisors reviewed and monitored every questionnaire for completeness, clarity, and consistency. The collected data were checked every day by the investigator and correction feedback was given every morning for supervisors and data collectors.
Statistical analysis was performed using SPSS version 20. Descriptive statistics were used to describe the frequency and percentage of each variable. Bivariable logistic regression was used to check which variables had an association with the dependent variable individually and multivariable logistic regression was conducted to identify factors that were associated with complementary food hygiene practices. All variables with p-value < 0.25 in bivariate logistic regression were moved into multivariable logistic regression. Then, independent predictors were determined to be predictive for outcome variable using p-value <0.05. Adjusted odds ratios with 95% confidence interval were used to write reports of the analysis.
To assess the level of knowledge on key moments for hand washing, mothers were asked one question that has a list of six correct answers. Each respondent is given a score based on the number of correct responses provided. Those mothers who scored less than the mean score were considered as not having knowledge and those who mentions greater than the mean score were considered as having knowledge on critical times of hand washing
Variables | Frequency | % |
Hand washing practice with soap at critical times* | ||
Before food preparation | 166 | 32.7 |
Before feeding baby | 108 | 21.3 |
Before eating food | 89 | 17.5 |
After toilet use | 414 | 81.5 |
After touching child stool | 347 | 68.3 |
Do you wash your child hand before giving food? | ||
Yes | 391 | 77.0 |
No | 117 | 23.0 |
Do you prepare food for the child separately? | ||
Yes | 467 | 91.9 |
No | 41 | 8.1 |
Do you cook child food thoroughly? | ||
Yes | 504 | 99.2 |
No | 4 | 0.8 |
Duration of cooked child meal lasts until served | ||
Immediately after preparation | 155 | 30.5 |
Less than 2 hours | 204 | 40.2 |
More than 2 hours | 149 | 29.3 |
Where you store child meal?* | ||
In the refrigerator | 41 | 8.1 |
Kept as hot | 9 | 1.8 |
Kept in room temperature | 458 | 90.8 |
Kept covered | 446 | 87.8 |
What do you do leftover stayed more than 2 hrs? | ||
Reheat always before feeding | 296 | 58.3 |
Never/sometimes reheat | 70 | 13.8 |
Discard | 142 | 28.8 |
Which methed do you use to feed your child?* | ||
Feed with spoon | 440 | 86.6 |
Feed with a bare hand | 207 | 40.7 |
Do you practice bottle feed? | ||
Yes | 178 | 35.0 |
No | 330 | 65.0 |
Which method you practice to clean utensils?* | ||
Wash with hot water | 282 | 55.5 |
Wash with detergent | 405 | 79.7 |
Wash with cold water only | 104 | 20.5 |
Do you wash raw fruits and vegetable before use? | ||
Yes | 490 | 96.5 |
No | 18 | 3.5 |
Child’s feces disposal practice | ||
Closed (in latrine) | 434 | 85.4 |
Open field | 74 | 14.6 |
Where you dispose other liquid wastes? | ||
Closed (in the latrine or in sewage pit) | 219 | 43.1 |
Open field | 289 | 56.9 |
Notes: *, multiple responses
More than half, 58% of mothers participated in the study reported they always reheat food when they want to give their child ready to eat food (cooked food) that stayed more than two hours at room temperature. Whereas 28% of the study participants discard it and 13.8% of them feed without reheat.
Concerning hand washing at critical times, most mothers, 81.5% washed their hands after visiting the toilet and only 32.7% of them reported they wash their hands before feeding their child. But the proportion of mothers who have practiced hand washing with soap at a critical time was lower. For instance, 17.5%, 21.3% and 32.7% of them were reported, they wash their hands with soap before eating food, before feeding baby and before preparing food, respectively (
The mothers were asked type of utensils or methods they use to feed their child. According to the result of the study, 86.6% of mothers feed with a spoon/cup, and 40.7% of them use their bare hands. From which 28.5% of mothers use both spoon and bare hand simultaneously to feed depending on types of food. For foods like bread and ‘
The majority of mothers, 79.7% and 55.5% use soap and hot water respectively to clean utensils used for child feeding, whereas some mothers, 20.5% used only cold water to clean utensils, while few numbers of mothers, 9% did not use soap and hot water at the same time to clean and sanitize spoons and plates used to feed their children.
Pertaining waste disposal practices, 15% of mothers dispose of the children’s feces to open field. Few mothers responded that they do not dispose child feces in the latrine; they throw out at other places; for example, near the fence where the adults’ feet could not reach. In addition, more than half of study participants, 57% practiced open field disposal of other liquid wastes generating from the household.
According to the result of the study the overall food hygiene practice of mothers was significantly associated with child age, growth monitoring follow-up, media exposure and knowledge of mothers on critical times of hand washing. Mothers of children aged 12-23 months practice 1.63 times good food hygiene than that of children aged 6-11 months of age (AOR, 1.82 95% CI (1.21, 2.73)). Mothers whose child attend growth monitoring session practice good food hygiene than their counterpart (AOR, 2.74 95% CI (1.49, 5.06)). The finding also identified that mothers who have media exposure practiced good food hygiene practices compared to mothers who have no media exposure (AOR, 0.73 95 CI (1.14, 2.62)). Mothers who have knowledge on critical times of hand washing have more likely to practice better food hygienic practices than mothers who does not have knowledge on critical times of hand washing (AOR, 1.94 95% CI (1.33, 2.82)). Educational status of mothers, occupation of fathers and marital status of mothers showed significant association in bivariable regression, but not in a multivariable regression model (
Predictor variables | Food hygiene practices | COR (95% CI) | AOR (95% CI) | |
Good (%) | Poor (%) | |||
Child age (in months) | ||||
6-11 | 72(47) | 83(53) | 1 | 1 |
12-23 | 207(59) | 146(41) | 1.63(1.12, 2.39)* | 1.82(1.21, 2.73)* |
Growth monitoring follow-up | ||||
No | 18(29) | 44(71) | 1 | 1 |
Yes | 2261(58) | 185(42) | 3.45(1.93, 6.16)** | 2.74(1.49, 5.06)** |
Mother’s educational status | ||||
No education | 24(39) | 37(61) | 1 | 1 |
Primary education | 130(53) | 115(47) | 1.74(0.98, 3.09) | 1.31(0.69, 2.45) |
Secondary and above | 125(62) | 77(38) | 2.50(1.39, 4.50)** | 1.42(0.69, 2.88) |
Marital status | ||||
Not in union | 5(23) | 17(77) | 1 | 1 |
In union | 274(56) | 212(44) | 4.39(1.59, 12.10)** | 2.54(0.86, 7.51) |
Media exposure | ||||
No | 68(45) | 84(55) | 1 | 1 |
Yes | 211(59) | 145(41) | 1.79(1.22, 2.64)** | 1.73(1.14, 2.62)* |
Father’s educational status | ||||
No education | 20(44) | 25(56) | 1 | 1 |
Primary education | 124(52) | 117(48) | 1.32(0.69, 2.51) | 0.73(0.34, 1.54) |
Secondary and above | 135(61) | 87(39) | 1.94(1.02, 3.70)* | 0.95(0.44, 2.07) |
Knowledge on critical times of handwashing | ||||
Doesn’t knows | 111(45) | 133(55) | 1 | 1 |
Knows | 168(64) | 96(36) | 2.09(1.47, 2.99)** | 1.94(1.33, 2.82)** |
Notes: **, statistically significant at p < 0.01; *, statistically significant at p < 0.05; COR, Crude odds ratio; AOR, Adjusted odds ratio; CI, Confidence interval
The result showed that 55% of interviewed mothers scored above the mean of overall food hygiene practices. Their practice of food hygiene is significantly associated with age of the child. Mothers of younger children had lower odds of practicing good complementary food hygiene than those of older children (12-23 months). This might be because most of the time mothers consider hygiene measures for their children when they become older, particularly hand washing for infants were not common. Mothers having media exposure and knowledge on critical times of hand washing practice relatively good food hygiene, compared to their counterparts. This confirms the reality that media exposure has a positive association with their knowledge, which in turn has a positive influence on their practice of good food hygiene. In addition, mothers whose child attended growth monitoring session practice good food hygiene than those who did not attend. This might be as a result of counseling given to mothers or caregivers during this session.
When we see handwashing practices of the study participants, the study showed that 33% of mothers reported they wash their hands with water and soap before food preparation. It was lower than study conducted in India, which was 74%
The study showed that 40% of mothers use their bare hand to feed the children. Of which only 19% of them wash their hands using soap and water, which also contributes to the contamination of complementary foods and in turn childhood illnesses
According to this finding, 29% of mothers store prepared child meal for more than two hours to serve it two times and more. The place where this food stored determines the level of contamination. If it refrigerated the bacterial multiplication becomes very slow. If it does not refrigerated it should be eaten soon, no more than 2 hours, before microorganisms have time to multiply. However, the study shown that only 8% of families store food in the refrigerator. Cooking small amounts of food which child can consume within a short period of time to avoid long periods of storage and spoilage is the first one choice and could solve the problems related to food storage practice especially in low-income families. Because there is the issue of lack of proper operation and maintenance of refrigerator, discontinuity in power supply or faulty of temperature control, it could be harmful for the food spoilage and contamination.
This study has shown that 30% of mothers feed always fresh food immediately after preparation and 29% of mothers store food for more than two hours to serve it for another time. This can increase the risk of contamination and diarrheal diseases among children due to the fact that microbial counts increased as food stored at room temperature and can reach its infective dose within two hours
The study also revealed that 58% of mothers always use the reheating method after serving left over. Reheating is easy to prescribe, but could be difficult, especially for poor and busy mothers to practice. The reason for reheating food among our mothers is another critical issue to be considered, because most of them practice reheating simply to make foods warm to make it palatable, rather than to destroy harmful microorganisms. As previous studies show, reheating foods before consumption can considerably reduce food contamination and the risk of illness
The mothers’ food hygiene practices were determined based on self-reported data which might introduce social desirability bias; and it could overestimate the appropriate practices. This limitation was considered in the study procedures while interviewing the mothers to minimize it as much as possible.
Food hygiene practices score of mothers was affected by factors like child age and media exposure. Usual handwashing practice with water and soap at all critical times were relatively low before eating food, before feeding children and before preparing food. The practice of food storage at an appropriate temperature was also low. Unhygienic child feeding methods, like bottle feeding and feeding by bare hand, are the identified undesirable food hygiene practices in the current study area.
The findings suggest the following recommendation for effective intervention strategies of infants and child feeding practices.
1. Urban health care workers and other health care staffs need to educate mothers on how they improve hygienic handling practices, especially for infants under one year of age.
Health care workers need to strengthen counseling mothers during growth monitoring sessions on complementary food handling.
We thank Madda Walabu University and town administration for providing permission, and data collectors, supervisors and study participants for their participation in the study.