Food hygiene is an integral cross-section between WASH and nutrition, especially for young children under five. Translated from Nyanja as, “Have you washed your hands with soap and water?”, this bib was given to participants in the Hygienic Family program in Malawi. Photo: Tracy Morse

Recent research from the WASH Benefits and SHINE trials has brought focus to the interconnections between water, sanitation, and hygiene (WASH) and nutrition. Based on this new evidence, there have been calls for a ‘transformative’ change in our approach to addressing water, sanitation and hygiene and improved integration of WASH and nutrition programmes in the fight to reduce diarrhoeal disease in children under the age of five. To date, we have yet to define what this transformative approach looks like. However, we do know that it needs to include a wider range of interventions than the traditional provision of water, toilets, handwashing facilities, and nutritious foods.

One key area that has been under-represented in interventions to date is food hygiene, and particularly the safety of complementary foods being provided to children under the age of five. A range of studies examining the safety of complementary foods over the last ten years have highlighted the risks associated with these foods, as they provide an ideal medium and significant route of diarrhoeal disease transmission.

For many years, the World Health Organization (WHO) has promoted five key areas of food safety: (1) keep clean (including hands); (2) keep raw and cooked food separate; (3) cook food thoroughly; (4) keep food at safe temperatures; and (5) use safe water and raw materials. These practices are, in principle, simple and straightforward. But for those living in low-income settings, with limited access to basic services such as water, electricity, and a secure food supply, providing their children with safe food can be a significant challenge.

As part of the SHARE consortium, the WASHTED Centre at the University of Malawi and the University of Strathclyde developed and trialled a context-appropriate intervention to improve food safety practices in rural households in Malawi. This behaviour-centred Hygienic Family (Banja la Ukhondo) programme ran for 9 months in 1000 households. Through mediating changes in behaviour and practices, the programme achieved a significant reduction in diarrhoeal disease. We also identified a number of non-health benefits arising from the intervention, such as improved relationships, increased social capital and female empowerment. Our key recommendations based on our findings include:

• Given the significant role that food plays in the transmission of diarrhoeal diseases and under-nutrition in low- and middle-income countries, food hygiene must be incorporated in existing related policies and strategies.
• Programme implementers should identify and integrate effective behaviour change techniques in existing community Nutrition and WASH programmes (e.g. Community Led Total Sanitation (CLTS) and Scaling Up Nutrition (SUN)). This study provides insights on appropriate actions required to address barriers related to food hygiene practices in this setting.
• More effort is needed to evaluate and assess the sustainability of WASH, food hygiene, and behaviour change interventions over longer periods.
• Finally, community-based implementation methods for interventions should consider the added value of non-health benefits such as improved social relationships, empowerment, and community social capital, which can benefit other developmental activities.

Learn more about the Hygienic Family programme here.