Food safety knowledge, attitudes and practices of mothers—Findings from focus group studies in South India

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Appetite 49 (2007) 441–449 www.elsevier.com/locate/appet

Food safety knowledge, attitudes and practices of mothers—Findings from focus group studies in South India G.M. Subba Raoa, R.V. Sudershanb,, Pratima Raob, M. Vishnu Vardhana Rao, Kalpagam Polasab a

Extension & Training Division, National Institute of Nutrition (NIN), Jamai-Osmania PO, Hyderabad-500007, AP, India b Food and Drug Toxicology Research Centre, NIN, Hyderabad, India c Division of Field Studies, NIN, Hyderabad, India Received 27 November 2006; received in revised form 14 February 2007; accepted 20 February 2007

Abstract In India, most of the diarrhoeal deaths among children (o5 years) are attributed to food and water contamination. Mothers are usually the final line of defence against food borne illnesses. Thus, the role of mothers in ensuring food safety at homes is well accepted. There are hardly any studies in India to understand their knowledge, attitudes and practices on food safety. The present study was an attempt in this direction. A total of 32 Focus Group Discussions were carried out with mothers of children o5 years in 16 districts from all the four South Indian states. The findings reveal that food safety awareness and practices are good among mothers perhaps due to the Indian food ethos passed on to them through generations. Home cooked foods are considered to be safer than prepared foods bought from outside. Many mothers were aware of the common food adulterants but do not bother to complain or take action. There is a need to create enabling environment with improved access to potable water, sanitation and cooking fuel. Spreading awareness about checking food labels and reporting to the health authorities in case of food poisoning or adulteration is also the need of the hour. The Anganwadi Centres can be the focal points for imparting food safety education to the mothers. r 2007 Elsevier Ltd. All rights reserved. Keywords: Food safety; Focus groups; Knowledge; Attitudes; Practices; Mothers

Introduction Food borne illnesses are a widespread public health problem globally. In response to the increasing number of food borne illnesses, Governments all over the world are intensifying their efforts to improve food safety. Although, the global incidence of food borne illnesses is difficult to estimate, it has been reported that in 2000 alone 2.1 million people died of diarrhoeal diseases. A great proportion of these cases can be attributed to contamination of food and drinking water. Although, the surveillance of food borne disease outbreaks have been fairly well established in developed countries, less than 10% of actual cases in these countries are recorded in official statistics. In case of developing countries it could be even less than one percent Corresponding author. Tel.: +91 40 27008921x321.

E-mail address: [email protected] (R.V. Sudershan). 0195-6663/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.appet.2007.02.011

(WHO, 2006). A significant proportion of food borne illnesses arises from practices in the home kitchen (Bryan, 1988; Scott, 1996; Scott, Bloomfield, & Barlow, 1982). Information is needed on how food becomes unsafe in the home and on what changes in environmental conditions, and in beliefs and behaviour, must be accomplished in order to reduce food hazards (Worsfold & Griffith, 1997). As Rozin and Fallon (1980) argue, awareness, knowledge and judgement on foods can be affected by the habits and other perceptions that result from social, cultural, and economic influences. This probably explains why comparatively lower number of studies are conducted on consumer attitudes towards food safety in the third world countries, where food safety may not be of as much interest due to low consumer impact (Wilcock, Pun, Khanona, & Aung, 2004). Consumer concerns about food are based on worries not only about health but also about food culture among others (Holm & Kildevang, 1996). Therefore, food safety

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the preparation of meals (NIN, 2006). The role of food handlers, usually mothers, in ensuring food safety and hygiene at household level is well accepted (Medeiros et al., 2004). An understanding of the status of their food handling knowledge and practices is needed. There has been limited, rather no research on food safety knowledge and behaviours of mothers in India. Quantitative techniques especially questionnaire surveys to elicit information on food safety practices certainly have some value indicating what people know but there is little information on whether the respondents actually behave in the way claimed (Worsfold & Griffith, 1997). In such a context, the use of qualitative techniques like focus group discussions (FGDs) have been well documented (Krueger, 1998). FGDs are a well-established method of getting participants’ understanding of and perspectives on certain issues through discussions. The focus groups usually constitute a group of 6–8 people, selected for their homogeneity on some factor important to the research, such as age or sex. Discussions are ‘focused’ on the topic of interest to the researcher (Millward, 1995). The present study was an attempt to assess food safety related behaviours and practices of mothers of children o5 years from South India.

concerns are not uniform to all cultures. Unlike in the West, in India adulteration is a major food safety concern because semi-processed primary agricultural produce and other raw material are procured from the market before they are further processed and made suitable for cooking at home. Similarly, improper cooking and cross contamination may not be perceived as major food safety threats in the Indian context because certain food safety measures are traditionally practiced by the people perhaps even without the knowledge of scientific rationale behind them. For example, traditionally, cooked food falls into two main classes—(i) Kuccha foods are those freshly cooked using water (like rice, unleavened bread called roti, cooked legumes called dal) and usually served hot to the family within the kitchen area. (ii) Pucca foods are those made using fat, which can be taken out of kitchen for consumption outside the family (like fried/deep fried snacks and savouries) (Achaya, 1998). This classification is probably based on the vulnerability of cooked foods to spoilage and contamination. In many Indian homes, domestic hearth is an area of purity and sanctity frequently next to the area of worship so it is usually located far from water disposal areas and well demarcated from sitting sleeping and visitor receiving areas. Before entering the cooking area the cook is obliged to take a bath and wear fresh garments (Achaya, 1994). Although, the innate cultural practices imbibed through generations have their own virtues, there is a growing concern about food borne illnesses in India. An estimated 4,00,000 children below 5 years age die each year due to diarrhoea. Several millions more suffer from multiple episodes of diarrhoea and still others fall ill on account of hepatitis A, enteric fever, etc. caused by poor hygiene and unsafe drinking water (UNICEF, 2004). Though most food borne diseases are sporadic and often not reported, in India, a nation-wide study carried out recently, reported an alarming 13.2% prevalence at household level (NIN, 2006). Home food preparers need to take many precautions to minimise pathogenic contamination of home-prepared foods because they are the final line of defense against food borne illnesses (Medeiros et al., 2004). In over 90% of households in India, it is the women who are involved in

Materials and methods Study setting After obtaining the clearance of the Institute’s Scientific Advisory Committee (SAC), which acts as the Institutional Review Board, the study was conducted in all the four southern states of India namely Andhra Pradesh (AP), Tamil Nadu (TN), Karnataka (KTK) and Kerala (KER). South India, despite cultural diversity typical of Indian scene, presents similarities in food habits that distinguish it from rest of India. Some demographic details of the study states are given in Table 1 (NFHS, 2000). These states were stratified into three broad categories (small, medium and large) based on the size of the population. They were further sub-stratified into regions and two districts were allotted to each region. Based on

Table 1 Important demographic details and food safety enabling assets of the four study states State

Population (in millions)

% of females literate

Under five mortality rate (per 1000 live births)

HHsa with piped water

HHsa with hand pump

HHsa with toilet

HHsa with LPGb

Andhra Pradesh Karnataka Kerala Tamil Nadu

75.9

46

85.5

51.7

26.8

72.7

16.7

6.4

52.3 32.4 61.9

55.5 85.1 58.3

69.8 18.8 63.3

68.0 17.7 63.3

19.0 2.2 30.6

61.4 14.8 65.9

20.3 15.3 37.7

9.8 20.4 23.4

Source: National Family Health Survey (NFHS)-2 Report-1998-99 (2000). a HHs—Households. b LPG—Liquefied Petroleum Gas (cooking fuel).

HHsa with refrigerators

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this, six districts from three regions of AP (large state), four districts each from two regions of TN (medium state) and two regions of KTK (medium state) and two districts from one region of KER (small state) were randomly selected. Two FGDs were carried out per district making the total number of FGDs 32 from 16 districts. The number of FGDs was limited by the convention that no more discussions need to be undertaken when responses begin to recur (Debus, 1998). Respondents The homogeneity of the participants in the FGDs was limited only to the fact that they were all mothers with at least one child below the age of 5 years. Other characteristics like literacy, economic and social status and age were not considered. Their age ranged between 18 and 46 years. Though most of the women were housewives doing domestic work, some of them occasionally worked on the farms and as domestic helps while a few were engaged in small jobs like tailoring, selling vegetables. There were very few women in each group who studied beyond high school, while some of them were educated up to the primary school level and the others were illiterate. Piped water was accessible only to about half of them, with only a few having the facility in their premises. In some areas especially in KER they draw water from open wells. Cooking fuel used by most of them was wood, cow dung cakes or kerosene (paraffin oil). Majority of them cook food twice a day and storing food beyond a day is not common. Though separate kitchens are not available in

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most of the households, there is usually a clearly demarcated cooking area with in the available space. Preparation of theme guides/discussion points In preparation for the FGDs, a theme guide containing questions (under relevant themes) was developed. This had the themes around which the discussions would focus. The specific questions were derived from a review of the literature (FSA Report, 2000; NFI (Nutrition Foundation of India), 2003; Worsfold & Griffith, 1997) discussions with food safety experts and social scientists. After conducting three pilot FGDs, it was realised that specific themes like personal hygiene, foodborne diseases and detection of food spoilage were yielding limited discussions. Hence broader themes like concept of safe food, qualities/indicators of safe food and measures taken to ensure food safety were included. The list of themes along with probes and what they aimed to elicit (information on knowledge, attitude or practices) are furnished in Table 2. Conducting FGDs In almost all the cases the mothers were contacted through Anganwadi Workers (grassroots-level health functionaries) and the purpose of the study was explained to them. Only those mothers who were willing to participate in the discussions were gathered in the Anganwadi Centres (grassroots level health centres run by the Government for the benefit of mothers and pre-school age children) or in the backyards of one of the members for the purpose of

Table 2 Themes for focus group discussions Themes & probes

To elicit information on Knowledge

Attitude

Practice

Concept of safe food according to you Probes—Cooked/uncooked, Home cooked/outside foods, What is unsafe food

|

—

—

Qualities/Indicators of safe food Probes: Do you think that food can ever turn harmful? Why? Do you judge the quality based on the way it is stored/served

|

|

|

Measures taken to ensure food safety Probes: In case of cooked/uncooked foods, fruits and vegetables, when buying from outside etc.

—

—

|

Common adulterants in your area and what do you do when you find food adulterated Probes: Site some examples

|

Quality parameters considered when buying food outside Probes: When buying Packed/unpacked foods Are labels checked? If so what is read Do you check how cooked food is being handled and served

|

|

|

Effectiveness of government in curbing food adulteration/poisoning

—

|

—

Previous exposure to food safety issues Probes: Did anybody speak to you about these issues earlier Do you see/hear about them in media Who do you think can spread the message of food safety in your locality

|

|

—

|

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discussion. Teams consisting of a moderator and notes taker, who were trained to conduct focus groups in a standardized way, conducted these discussions. The mothers were seated in a semi-circle with the moderator in the centre. The FGDs were conducted in Telugu, Kannada, Tamil, Malayalam and Hindi (the local languages). The discussions were recorded using audio devices such as dictaphone with the permission of the respondents. Analysis The recorded discussions were transcribed on the day after the discussion by the moderators using the notes taken by the observer to supplement the tape recordings, especially when more than one person had spoken at the same time. The Telugu/Kannada/Tamil/Malayalam/Hindi scripts were translated verbatim into English by the respective teams (moderators and notes takers). These scripts were in turn compiled into individual reports by one of the investigators (GMSR) with the help of the respective moderators by organising raw data into codes (as per the method suggested by Newman, 1994), based on the themes. Then, separate documents were produced for each state by including the comments of mothers of the respective groups in response to the themes raised during the discussions. These reports were read independently by two other investigators (VSR and PR) who agreed on the interpretations at both the stages. All these individual state reports were in turn compiled and the similar findings were grouped under the themes with relevant comments to present the following results. Findings & discussion Concept of safe food In all the four states, safe food was considered to be the food that is cooked in clean utensils, after washing hands, by using fresh vegetables and served hot. Most of them spoke about usage of fresh ingredients and personal hygiene as the pre-requisites of safe food. Food that is prepared hygienically, that is, after washing vessels and washing vegetables is safe. Using boiled water for cooking and covering cooked foods also ensure food safety. (27-year old, primary school educated, Madurai District, TN) Just by keeping the surroundings clean, food doesn’t become safe but personal hygiene is also important to have safe food. (40-year old, illiterate, Srikakulam District, AP) Women who were unable to define ‘safe food’ chose to define what was ‘unsafe’. They felt that stale foods or foods in which rotten vegetables are used and those, which un hygienically, were unsafe.

Use of rotten vegetables and unwashed vegetables will make the food unsafe. (28year old, primary school educated, Karur District, TN) Left over food is unsafe as it causes fever, vomitings, diarrhoeaysometimes if air circulation is not there food gets spoiled. (32-year old, high-school educated, Srikakulam, AP) In KTK and AP, the mothers felt that food could turn harmful when it is stored for longer duration or due to high temperatures. They felt that food would become sticky or emanate foul smell when it turns harmful. In some parts of TN and AP, a majority of them felt that food turns harmful when hands are used to serve cooked foods. They stressed on the need to use only spoons to serve cooked foods. Due to heat and unclean circumstances food turns harmful. It smells bad and becomes sticky and bacteria will start forming on the food. So, the food that is stored in a cool place is safer. (23-year old, high school educated, Gadag District, KTK) If we handle the food with our dirty hands and again put the same hands in many dishes and serve, then it turns harmful. (29-year old, illiterate, Chittoor District, AP) When probed as to what was safer between cooked and uncooked foods, the mothers felt that cooked foods were safer. When asked about raw foods, they said there are certain vegetables, which can be consumed, raw. All of them felt that such vegetables have to be washed thoroughly before consumption. Some of them pointed out that they were even concerned about pesticide residues on fruits and vegetables. The food will be safe and tasty only if it is cooked or boiled properly. Some people eat half-boiled stuff, but I do not think it is safe. We should also wash vegetables before cooking. (37-year old, illiterate, Gardag District, KTK) Fruits and raw vegetables should be washed properly as they contain fertilizers and chemicals that have been sprayed on them. (18-year old, Primary school educated, Karur District, TN) Food safety is defined as food that is free from all hazards, whether chronic or acute that may make food injurious to health of the consumer (FAO & WHO Report, 2003). However, the term ‘safe food’ represents different ideals to different audiences (Elmi, 2004). The above findings indicate that the respondents in the study area stressed more on ensuring safety of foods at household level because they perceive physical and biological contaminants as the major hazards. Since all of them process raw foods to a large extent before they are made suitable for consumption, they wash/clean foods to free them from physical contaminants and cook them thoroughly for removing biological contaminants. Therefore, their concerns revolve around freshness, cleanliness and hygiene of

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food at all levels of domestic food handling. The growing concern about pesticide residues was also obvious in some areas. This to a large extent is fuelled by their exposure to recent controversy about pesticide residues detected in carbonated beverages, covered extensively in media. In a similar study conducted in a different context in the United Kingdom, it was reported that there was no consensus on what people perceived about food safety, however, the study reported that the respondents from Hindu and Muslim backgrounds in the sample seemed more concerned about food hygiene (FSA, 2000). In the Indian cultural context too, the object of cooking is not simply to produce material suitable for eating, but to conjoin the cultural properties of the food with those of the eater. For instance, vegetables almost always need the application of fire to make them edible. Cooking them means that they may be ritually washed to render them of sufficient rank to be permitted to enter the food area (Achaya, 1994). In the present study, many participants, especially in all groups in KTK and from the coastal districts of AP, stressed on the need to boil water to make it ‘safe’ for drinking. This may be due to the fact that the discussions were conducted immediately after the monsoons, when public campaigns by the government machinery were intensified to promote consumption of boiled water to avert waterborne illnesses in the regions. Research in other parts of the world also suggest that many people’s stance on food safety issues change depending on their mood or the last thing they have read or seen (FSA, 2000). Home cooked foods or outside foods The mothers expressed that food at home is prepared hygienically in clean utensils, with washed vegetables and is stored in covered containers. Almost all of them considered cooked foods purchased from restaurants, eateries, takeaways etc. as unsafe. Some of the mothers said that one cannot be sure of the quality of ingredients used in foods prepared by someone else, while some others said that they would go to reputed hotels or eateries since they feel that the food at these places is cooked and served hygienically. Home food is safe as it is prepared at home in a hygienic environment. Care is taken to wash vegetables, utensils, whereas, outside foods are not safe as workers do not maintain hygiene. For instance, they put their hands in their hair and again continue cooking with the same hands. (28-year old, graduate, Srikakulam District, AP) In some hotels glasses and tables appear very clean but you never know! Any how we rarely go to hotelsy can’t afford to eat out frequently. (30-year old, illiterate, Gadag District, KTK) I do not prefer eating food from hotels or restaurants as large quantities of food is prepared and less care is taken

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during preparation. (A 25-year old, high school educated, Kasargod District, KER) These perceptions of mothers are in tune with those of the people in developed countries who also perceived that foods prepared by someone else involved an element of risk usually attributed to concerns regarding unhygienic premises and poor staff training (FSA, 2000; FSAI, 2003). Packed foods and food labels Most of the mothers generally perceived that packed foods were safer than open foods sold in the eateries, because they presumed that the packets protect the foods from exposure to flies, insects and dust. A small number of mothers however felt that packed foods could be unsafe as they cannot be certain about the ingredients used. Packed food is always good, because it is away from mosquitoes and dust. (22-year old, high school educated, Mysore District, KTK) Many mothers in TN, AP and KTK were not in the habit of checking labels on food packets, as they were illiterate. In some cases, the mothers mentioned that they did not bother about this, as their husbands bought the foodstuffs. However, others ensured the quality of the foodstuffs by buying from known grocers always. My husband usually does the purchases; he checks the date on packed foods. (26-year old, illiterate, Krishna District, AP) Almost half of the mothers from both the groups in KER said that they check the labels for brand name and ‘best before’ date. Many of them do check for quality symbols like ‘ISI’ (Indian Standards Institute) and ‘AGMARK’ (Agriculture produce (grading and marking) Act). The same was reported by few women in KTK and TN too. Most of us see the package when buying packed foods. If the cover is beautiful, we buy it. We can judge whether it is good or not from the sight of it. Of course, we all see manufacturing date and expiry date. (46-year old, primary school educated, Kottaym District, KER) Educated people can only read and understand all that is given on the label. We can only check the date of manufacturing and usually all packed foods are safe for at least six monthsy ISI products are good in quality. I sometimes check for this mark as well. (39-year old, illiterate, Gadag District, KTK) When I buy packed food, I always note expiry date and manufacturing date. But I don’t think everyone does this. (22-year old, high school educated, TN) Since I cannot read I ask the shop keeper to check and tell me the date.(32-year old, illiterate, Adilabad District, AP)

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Some mothers in TN expressed a concern when they said, ‘‘Certain packed foods do not have labels or expiry date. What can we do?’’ This could be due to the fact that most local grocers pack the products themselves not complying with the labelling regulations. Earlier, in case of unpacked food products, we used to personally check whether they were clean or not. Shop owners these days are packing even sugar, pulses and cereals. How can we be sure that they are all clean? We cannot be certain of the weight also! (38-year old, illiterate, Mysore District, KTK) Though, studies in other parts of the world reported that about 40% of the consumers do not check the food labels (Surujlal & Badrie, 2004; Yang, Angulo, & Altekruse, 2000), it was observed that women, more so those with higher educational levels, were more likely to check food labels than men (FSAI, 2003; Yang et al., 2000). In the present study too it was observed that the literate respondents were more likely to check label information. In KER this trend was clearly seen perhaps because it is the state with highest literacy rate in India (Census, 2001). Measures taken to ensure food safety In order to ensure safety of cooked foods, women indicated a number of measures such as using fresh vegetables, cleanliness of surroundings, cooking in washed utensils, covering the foods while and after cooking and using spoons to serve. Most mothers also spoke about the need to wash hands thoroughly after using the toilet and the need to maintain personal hygiene. In all the four states many mothers felt that personal hygiene was the prerequisite for ensuring food safety. Taking a bath before cooking was reported to be the most essential measure. This is a practice that is perhaps ingrained in them as an age-old tradition, it is indeed in the Indian food ethos to invariably have bath before cooking (Achaya, 1994) Keeping the house clean and keeping ourselves clean is the basis for preparation of safe food. (23-year old, high school educated, Hyderabad District, AP). Similar views were expressed in other groups too. ‘‘We usually cook after having bath’’, said a respondent, to this two more young mothers of the same group added, Only if there is an urgency, we cook before taking bath, otherwise we usually take a bath before cooking. (29year old, illiterate, Hyderabad District, AP) It is known that poor hand washing practices inevitably lead to retention on the hands of bacterial and viral pathogens, which are obtained from handling raw produce or from toilet activities (Snelling, Kerr, & Heritage, 1991). In the present study, though most of the mothers reported of washing hands after using the toilet, cleaning the child’s stools and after handling cattle/pet and mopping/dusting the house as important measures to ensure food safety,

very few of them seemed to be using soap. Some of them reported using ash for washing hands. In contrast, in a study carried out in West Indies, it was reported that 88.1% of consumers washed their hands thoroughly with soap before and after preparing meals while only 10.7% did so ‘sometimes’ (Surujlal & Badrie, 2004). In the National Australian food safety telephone survey, most people (82.3%) reported that they washed their hands with soap or detergents and almost the same proportion felt it was very important to wash hands before and after preparing meals (Jay, Comar, & Govenlock, 1999). In AP, mothers seemed to be little more careful than their counterparts in the other states, when they said that they usually filter drinking water and avoid using water that is stored for many days. While purchasing fruits and vegetables, they usually check them for insect infestation and after procurement they wash them. Some of them also mentioned a variety of measures to store vegetables and fruits assuming that their practices were ensuring food safety. I wash the vegetables bought from the market and keep them in a wet cloth or in plastic covers and every day the cover is turned inside out to maintain the freshness of the vegetables. (19-year old, illiterate, Srikakulam District, AP) The first precaution I take before cooking is washing hands with soap. Without doing this, cutting vegetables or feeding the child is dangerous. (28-year old, illiterate, Villuppuram District, TN) In AP, few mothers were so over cautious that they washed cut vegetables and grains excessively. They did not seem to realize that excessive washing of vegetables after cutting them would lead to a loss of some nutrients (NIN, 1998). In some parts of AP, mothers said that they wash vegetables by dipping them in a container of water instead of washing them under running water. We wash the cutter, vegetables and kitchen before cooking and as for vegetables like carrot, tomato which we eat raw, we wash them with drinking water by putting them in a bucket. (24-year old, high school educated, Adialbad District, AP) We prepare food under clean conditions, clean the stove, utensils, wash green leafy vegetables by taking water in a vessel. We cut the green leafy vegetable and again wash them; we also wash rice three times with water. (23-year old, primary school educated, Ranga Reddy District, AP) The usage of running water for washing vegetables is not possible in all homes in India, since there is substantial heterogeneity in water delivery, with no dominant mechanism. Despite achievements in improving access to safer sources of water in the 1980s and 1990s, the current system of household water provision in India is unable to provide convenient and safe access to drinking water for a large

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sector of the population (Mckenzie & Ray, 2004). The situation is no different in these four study states too (Table 2). Common adulterants All the mothers seemed to have encountered food adulteration at some point of time. The commonly stated instances of adulteration were adulteration of milk with water, expensive oils with cheap oils, wood powder/ artificial colour in red chilli powder, powdered tamarind seeds in coffee, papaya seeds in pepper, pebbles in rice and pulses and suji (semolina) in sugar. In some areas of AP, onion and potato paste was used to adulterate ginger and garlic paste. When asked how they detect adulteration in different products, the mothers in TN said they usually identify only while cooking or by tasting. Some mothers in AP stated that they could recognise most adulterants by the texture or appearance. Certain foods when examined by hand can be identified as adulterated. For instance, brick powder in red chilli powder can be identified by its coarse texture. (35-year old, illiterate, Villuppuram District, TN) When we let a drop of milk to trail at the back of the palm our hands, if it does not leave a streak, it can be considered adulterated with water; tamarind when put into water, will leave all mud. (30-year old illiterate, Uttara Kannada District, KTK) Though the problem of adulteration of foodstuffs is rampant in India, women did not seem to be too concerned about this. With about 11% of all foodstuffs being adulterated in India (Ministry of Health and Family Welfare (MOHFW), 2004) this problem seems to have become a way of life that most people do not seem to consider it as a health hazard. However, they seem to have evolved their own methods to detect adulteration in certain foodstuffs. Most of the adulterants (like water in milk, chalk powder in turmeric and artificial colour in chillies powder) cited by the women in the present study matched with those reported by North Indian women in an earlier study (Beniwal & Khetarpaul, 1999). Measures taken if the food is adulterated By and large, mothers were not aware where and whom to complain in case of adulteration. Most of the mothers said they would return the product to the shop from where it was bought or they pick up a fight. They also added that they would never go back to the same vendor again to buy foodstuffs. However, some mothers in KTK said that though they were aware of the consumer courts, they did not bother to lodge complaints as they considered these to be ‘petty’ issues.

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We sometimes realize that the foods are adulterated. So we return it to the shop from where it was purchased and do not buy that particular brand again. (27-year old, high school educated, Karur District, TN) If we try to return the item to the shopkeeper, he will not accept. There is no point in arguing. We just lose our money. We cannot do anything sometimes. So better not to complain and waste our time. (30-year old, graduate, Kottayam, KER) These are so common that we do not bother to complain anywhere. We do not even know where to complain. (38-year old, illiterate, Mysore District, KTK) Similar findings were observed even in developed countries. A study in UK reported that in case of adulteration or unsatisfactory meals, most of the consumers were content to resolve never to visit that establishment again (FSA, 2000). From a qualitative survey among adult consumers in Ireland, it was reported that very few consumers had ever attempted to report a concern about food safety to the authorities (FSAI, 2003). Effectiveness of Government in curbing food adulteration and food poisoning Most of the respondents across the states were of the opinion that the Government machinery was not effective in curbing cases of food adulteration or food poisoning. Most of them ridiculed the quality of foods sold in the Government run fair price shops and they said the government should itself check the adulteration that is rampant in the public distribution system. However, some of them felt that the Government neither bothers to create awareness among villagers nor to implement the laws effectively in the villages. In AP, some mothers suggested that the shops should be given certification in order to avoid adulteration and the Government should create awareness through frequent campaigns in the community. It is obvious that the mothers are not aware that any outlet or grocery needs to adhere to the regulations laid down under the Prevention of Food Adulteration Act (PFA, 2004). In TN most of the mothers attributed such scenario to the rampant corruption across the rank and file of the executive. In KER, one group felt that the Government was effective while the mothers from other groups could not comment on this issue. Two years ago, the district collector used to personally check adulteration in shops. At that time adulteration was controlled. But after his transfer adulteration is rampant again. Therefore the government should be vigilant as it is the common people who suffer on account of this. (26-year old, primary school educated, Villuppuram District, TN) Government (through its fair price shops) itself is supplying adulterated food stuffs to us. In rice and wheat, they mix pebbles or other powders. What are

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they doing for us? (39-year old, illiterate, Gulbarga District, KTK) In India, the complacent attitude of the general public due to illiteracy, ignorance and dejection has probably led to a state of mass inertia, with the result, the entire burden of controlling the quality of food stuffs rests with government and its enforcement machinery (Gopalakrishnamurthy, 1985). Inadequacy of staff and general laxity of administration are one set of causes for malfunctioning of the PFA Act in India (Shah, 1985). Perhaps some of these issues may be behind shaping the women’s opinions in the Indian context. Elsewhere in the world too, Government machinery seems to be falling short of people’s expectations (FSA, 2000; FSAI, 2003). Previous exposure and preferred sources for seeking information on food safety Most mothers across the groups said no body had discussed these issues with them so far. However, mothers from one group each from TN and KER stated that issues related to food safety were discussed in the group meetings at the Anganwadi Centres (community health centres for mother and child) rarely. Some mothers in KTK said they even discussed these issues in a few meetings of the panchayat (village level self governance body). In Kottayam, district of KER, the mothers participated in sessions taken by local doctors. Classes relating to food and drugs were conducted by Doctors and health authorities. I think these are the right people to talk about these issues. (28-year old, primary school educated, Kasargod District, KER) When probed about the preferred means to know about these issues most of them liked to learn from Anganwadi centres, from doctors and preferred discussion as the mode of communication. Direct discussion is always better. If information is given on radio or TV only few people can get the information. It is better if concerned department officials come and explain in group discussions to help us understand properly. (40-year old, illiterate, Mysore District, KTK) In fact, many mothers in rural India see Anganwadi Centres as sources of information regarding various health issues. In this context the idea that these centres could be focal points for initiating awareness programmes on food safety is understandable. A study carried out in a western Indian state reported that the Anganwadi Workers proved to be effective in imparting food safety education to the women (Sheth & Obrah, 2004). Conclusions The present study indicates that the mothers in all the four South Indian states are generally aware of the

concepts of food safety. It appears that the alarming rate of diarrhoeal deaths among children (o5 years) may not be directly attributable to lack of food safety related knowledge but due to a variety of reasons that are beyond the control of the households. For instance, lack of access to potable water and constraints related to cooking fuel and sanitation in many households seem to be the main reasons for their practices not matching the knowledge. Ensuring food safety at household level depends to a large extent on creating enabling environment with immediate emphasis on providing access to potable water, cooking fuel and sanitation. As regards the existing safe food handling practices, though there are subtle differences within the groups, most of them are attributable to the innate cultural and behavioural attitudes and practices that have been passed on to them for generations. Although they are able to directly relate aspects of personal hygiene to food safety, the importance of usage of soap for washing hands has not percolated. There was a general perception that home cooked foods are safer than prepared foods bought from outside. Most women were aware of the common adulterants in foodstuffs, but alerting the regulatory authorities in case of adulteration does not figure as an option because most of them lack confidence in the Government machinery. This attitude is largely responsible for their acceptance of food adulteration as a way of life. This scenario is perturbing because there were some instances of food adulteration especially that of edible oils with argemone (Argemone Mexicana) oil leading to deaths (Singh et al., 2000). Literate respondents were more in the habit of checking labels on packed foods than their illiterate counterparts. However, efforts can be intensified to familiarise quality symbols on food labels, which can be identified even by the illiterates. At the same time, reporting to the health authorities in case of food poisoning or adulteration needs to be inculcated among the people. From this study, it can also be concluded that the Anganwadi Centres can be the focal points for food safety education to the mothers. The group discussions have an inherent limitation that the individuals may not produce the most accurate picture of their food safety behaviours and there is always a possibility of reporting their best behaviour in order to present themselves favourably to others in the groups. Carrying out observational studies may give more accurate inferences about the food safety knowledge, attitudes and practices of mothers.

Acknowledgements We thank the Ministry of Health and Family Welfare, Government of India for supporting the study. The investigators are also thankful to Dr. B. Sesikeran, Director of NIN, for his encouragement; and all the participants for participating in the study. Thanks are also

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