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Food safety awareness and food handling practices among rural population of Tamil Nadu

Food borne diseases (FBD) are illness caused by consuming contaminated food or drink.The contamination can occur anywhere from farm to the plate and can lead to a variety of avoidable diseases such as acute gastroenteritis, viral hepatitis. According to Food and Agriculture Organization, access to safe and healthy food is one among the essential rights of a human being. However, this right to safety food is often compromised. As per WHO report, more than 150 million people in the South East Asia region fall ill due to food borne diseases, with a mortality rate of around 175 million. Around 1/3 of these figures constitute children under five years. Many studies have shown that majority of food borne illness affect the developing countries of the world, of which Indian subcontinent had the highest incidence of acute diarrheal diseases. According to Integrated Disease Surveillance Program, in India alone, there were more than a 1000 cases of food borne diseases reported in 2016.


INTRODUCTION
Food borne diseases (FBD) are illness caused by consuming contaminated food or drink. 1 The contamination can occur anywhere from farm to the plate and can lead to a variety of avoidable diseases such as acute gastroenteritis, viral hepatitis. According to Food and Agriculture Organization, access to safe and healthy food is one among the essential rights of a human being. However, this right to safety food is often compromised. 2 As per WHO report, more than 150 million people in the South East Asia region fall ill due to food borne diseases, with a mortality rate of around 175 million. Around 1/3 of these figures constitute children under five years. 3 Many studies have shown that majority of food borne illness affect the developing countries of the world, of which Indian subcontinent had the highest incidence of acute diarrheal diseases. 1 According to Integrated Disease Surveillance Program, in India alone, there were more than a 1000 cases of food borne diseases reported in 2016. 4 and consumption. To emphasize the importance of food safety, the theme for World Health Day in 2015 was "From farm to plate, make food safe". The theme set out to educate the masses on food safety, new threats to food safety, food trends and preventive methods in order to strengthen food safety systems globally. 5 In India Government has its own governing body of Food Safety and standards Authority of India (FSSAI), which also supervise food safety and provide regulatory standards for food production. 6 In spite of many regulations and guidelines, the incidences of food borne illness still continue to prevail. According to a nation-wide study conducted, the prevalence of food borne illness at the household level was 13.2%. Data from the same study also showed that 40% of the food poisoning cases occurred due to home cooked food. 7 The high prevalence of food borne illness at home could be attributed to poor food hygiene and preparation due to poor awareness of proper practices. The present study is being conducted to assess the awareness, knowledge and practice of food safety at home among rural population in Kancheepuram district of Tamil Nadu state.

Study type
The study was a cross sectional study conducted in Kelambakkam village, Kancheepuram district of Tamil Nadu state, India

Study duration
The study was conducted from November 2016 to April 2017.

Sample size determination
From the previous study it was found that prevalence of food awareness was found to be 13%. Sample size for cross sectional study with 13% prevalence, 5% relative error and 10% non-response rate, the sample size arrived was 200.

Sampling and study population
The study population comprised of residents of Kelambakkam village of Thiruporur block located in Kancheepuram district of Tamil Nadu. Accoroding to census 2011, there were 13 blocks in Kancheepuram district. Simple random sampling was used to select one block (Thiruporur block) from 13 blocks. Out of 50 villages in Thiruporur block, Kelambakkam village was selected by simple random sampling with lottery method. As per population census 2011, the village has total population of 7984 with 3992 males and 3992 females. Houses in the village were enumerated and participants were enrolled by systemic random sampling methodalternative houses after choosing first house randomly. One person either male or female whomsoever available at the house at the time of data collection was included from each house. Inclusion criteria: 1) Residents of ≥18 to 60 years of age 2) Residents of the village for more than 6 months. Those who cannot be contacted even after three visits were excluded.

Data collection procedure
After obtaining written informed consent the participants were interviewed using pretested questionnaire by trained investigators in the local language i.e. Tamil.

Study instrument
A pretested, validated study questionnaire was used to collect the data. The study instrument comprises of four sections. Section 1 comprises of Socio-demographic details such as age, sex, education, occupation, marital status, socioeconomic status (modified BG Prasad classification). Section 2 comprises of knowledge on food handling practices. Section 3 include attitude towards food practices like washing of vegetables, eating of raw vegetables, intake of carbonated/beverages and energy drinks like Horlicks, Bournvita etc. and attitude towards food poisoning. Section 4 include questionnaires regarding food hygiene practices at home like food habits, source of drinking water and milk, method of cooking of egg and milk products, hand washing practices, methods used to clean vegetables/fruits, storage of cooked food items, frequency of gastroenteritis infections among family member in last one year.

Outcome variables
The outcome variables include those which assess the knowledge and attitude towards food hygiene and food handling practices at home.

Statistical Analysis
Data was entered in Microsoft Excel spread sheet and analyzed in Statistical Package for Social Sciences (SPSS -IBM) software version 21. For qualitative variables proportions for quantitative variables mean, median, range and standard deviation were calculated. Data were assessed for normality before applying tests of significance. Chi square test was applied. P<0.05 was considered significant.

Ethical consideration and confidentiality
Institutional Ethical Committee approval was obtained before starting of the study. Confidentiality of study participants was maintained in all the phases of the study.

RESULTS
Totally 200 participants were studied. Majority (40.5%) of the study participants were between 31-45 years of age. Almost 36% of the cases were unemployed.
On assessing the knowledge on food safety, around 24.5% had no knowledge about overcooking.48% said that reheating of food is not harmful and 26.5% did not know that foods which are not freshly prepared could cause food poisoning (Table 2).      Among the study participants around 43.5% had the attitude that carbonated drinks help in digestion and 41.5% had the attitude that food supplements like Horlicks, Bournvita etc. are more important in growth and development than cereals, veg, fruits etc. (Table 3).
Around 86% of the study participants were Non Vegetarians. Source of drinking water for most of them were hand pump water (46.5%) and around 38.5% consume packed milk.98.5% consume milk only after boiling it. 31.5% had at least 1 episode of Acute Gastroenteritis last year (Table 4).
Among those who have adequate knowledge (59) (29.5%), only 25(42.3%) had adequate practice (Table 6).  9 When asked about correct method of washing 66.5% said that washing before cutting is correct whereas 33% said washing after cutting is the correct method.

DISCUSSION
According to 26.5% and 14% study participants consuming food not freshly prepared will not and not necessarily cause food poisoning respectively.
In this study, upon investigating the food safety behavior, it was found that 52% subjects wash their hands before and only 8% wash after handling raw food and only 37% was before and after handling raw food. A study done by Sudershan et al in Hyderabad showed that 100% wash hands before and 98% wash hands after cooking and 90% wash hands both before and after cooking. 10 A similar study done by Byrd-Bredbenner et al showed that 79% wash hands before cooking. 11 A study done in Delhi showed that only 23.5% wash hands before cooking before health education. 12 Hand washing, done properly before and after handling food is the most effective way to prevent food borne illness.
Among those who have correct knowledge only 25 subjects practices adequate food handling practices.
In this study among those who don't have adequate safety practices, around 60 developed age in the last year. According to a study done by Sudershan et al, around 21% developed food borne illness in the previous year. 10 The safety of cooked food and raw food depends only on the temperature at which it is stored. Unless proper thawing before reheating the foods tend to get spoiled. Also flies and rodents in the kitchen infest microorganisms leading to age. Proper washing before and after handling raw foods, washing of all the vegetables before cooking and eating freshly prepared food will reduce the chance of getting age.

CONCLUSION
Food safety starts from the farm to the plate. Food contamination can occur anywhere in the food cycle. Food sanitation starts from personal hygiene, germ free preparation area to the dishes being microbes free. Food contamination can lead to disease outbreaks and can lead to food borne illness and intoxication. This study demonstrates that the knowledge towards food handling is not adequate and those who has adequate knowledge don't practices it regularly affirming the old saying "Knowledge is of no value, unless you put it into practice". Continuous Food safety education in rural areas and motivation is needed to increase the awareness about the WHO's five key principles of food hygiene 13 , which are keep clean, separate raw and cooked food, cook thoroughly, keep food at safe temperatures and use safe water.