We developed a definition of high-risk foods before conducting field work. High-risk foods included mashed and mixed foods, which were likely to have the greatest risk for pathogen transmission, since their preparation involved manipulation with bare hands, after which the foods were not further cooked. In assessing level of risk, we also considered the moisture content of foods, which was assessed based on our familiarity with the way of preparation rather than measuring quantitatively, as moisture provides a favorable environment for rapid pathogen growth.5,25 We looked at three types of foods: bhortas, salads, and naasta. “Bhortas” are dishes made from hand-mashed vegetables, fish, or fruit. Salads typically consist of dishes made from hand-mixed raw vegetables with other ingredients like onion and chili. Under the salad category, we looked at “paan” (betel quid), a recreational substance for chewing, prepared with betel leaf combined with areca nut and/or cured tobacco using hands.26 “Naasta” are preparations made from dry snacks hand-mixed with other ingredients like onion and chili.
We specified handwashing opportunities before high-risk food contact: 1) when foods came into direct contact with hands and were not further cooked, for example, mashing foods, mixing salad, mixing dried foods and 2) when cutting or peeling raw vegetables, fish, or meat immediately before preparing high-risk foods. We defined hand rinsing with water as washing hand(s) using only water with minimal rubbing. We defined hand contact with water when hand(s) were dipped into a bowl of water or water was simply poured over the hand(s) without any rubbing. Study sites and population. This formative research study was conducted in three rural villages of Kishorganj District, in central Bangladesh. We selected the sites to represent a typical rural area of Bangladesh in terms of water points and latrine facilities (i.e., shared tube wells with hand pump and shared latrines, both situated outside of the household) in which no handwashing intervention had been implemented. Most study participants were caregivers of children less than 3 years of age who prepared food for the child as well as for the household. We also included heads of households, the elder person of the family, for example, father, grandfather, or grandmother of the child, as in the Bangladeshi context elders are important family decision makers. Household heads decide how to manage household issues, including funding and arranging water, sanitation and hygiene facilities, for example, buying soap. Data collection methods. From November 2011 to January 2012, the data collection team sequentially used semi-structured observations, video observations, in-depth interviews, and focus group discussions.
Group discussions. Semi-structured observations and video observations recorded food preparation activities, which focused on the steps of preparing each category of high-risk food and the related handwashing opportunities and practices. In-depth interviews and focus groups explored the various types of each category of food that community members prepared and consumed, the foods given to children, the perceptions regarding hand hygiene around food preparation, and the barriers to washing hands with soap at these events. In addition, focus groups identified the broader community norms on food preparation– related handwashing. In exploring such factors with the study participants, we were guided by the Integrated Behavioral Model for Water, Sanitation and Hygiene (IBM-WASH),27 a theoretical framework that integrates the multilevel factors influencing water, sanitation, and hygiene behavior, in three dimensions: contextual, psychosocial, and technological. A sociologist (Fosiul A. Nizame) led the data collection. Four experienced anthropologists conducted the semi-structured observations, in-depth interviews, and focus group discussions, while women from the study communities who had completed at least their secondary school certificate examination conducted video recordings of household activities. Experienced anthropologists trained the women to use the video camera and explained the activities to record during video sessions. Each woman made a short trial film to ensure that she had acquired the skills. Sampling and data collection. The data collection team selected study participants purposively. Only one caregiver was included from a compound, a group of houses surrounding a yard with occupants who share a familial relationship and typically share access to water and latrines. During enrollment, the data collection team included approximately the same number of child caregivers from each child age category: 0–12, 12–24, and 24–36 months, as there were likely different feeding practices and food types for each. The data collection team conducted 12 semi-structured observations, 12 video observations, and 12 in-depth interviews; six in-depth interviewees had also participated in the semi-structured or the video observations, while 24 enrollees participated in only one data collection activity. Anthropologists found data saturation after analyzing 12 in-depth interviews and did not proceed further to enroll in-depth informants.
For video observations, with the help of village residents, the field team identified the main entry point of each of three villages, as a starting point to include eligible caregivers, and selected four households per village, each household coming from four different adjacent compounds, for a total of 12 video observations. For semi-structured observations, the field team started the enrollment of eligible caregivers from the end point of each of the three villages, as identified by villagers. Four semi-structured observations per village were conducted in households coming from each of four different adjacent compounds for a total of 12 semi-structured observations. Although the objectives for video and semistructured observations were the same, the video provided the study team with a visual record, which could be reviewed after leaving study sites, to aid data analysis. Each household was visited to take informed consent, to enroll the participants, collect basic demographic and socioeconomic information, and for an informal discussion on daily household activities to fix a feasible time and day for data collection activities. During this visit, anthropologists asked caregivers when they would next prepare and consume mashed and mixed foods, and the data collection team scheduled the observation to take place at that time. The team conducted semi-structured observations during two different periods in each household: from 7:30 AM to 11:30 AM and 6:00 PM to 8:00 PM, whereas video observation was conducted only during the morning period as there was insufficient lighting in the evening in study sites with no electricity.