Introduction
In low-income contexts, malnutrition is a critical factor in the morbidity and mortality of children under five years. 45% of all deaths of children under five in low and middle-income countries are linked to undernutrition, and 61.4 million children in Africa were stunted in 2020 [
1]. Poor water, sanitation, and hygiene practices, including food hygiene, contribute to poor childhood nutrition through the ingestion of microbes that cause diarrhea. Exposure to food contaminants can occur due to inadequate handwashing habits, food handling, preparation, storage, and oversites during cultivation, harvest, and transportation to the household [
2‐
4]. Unsafe food can contain harmful bacteria, viruses, parasites, and chemical substances which cause many diseases including diarrhea [
5]. Since bacteria, viruses, and parasites are invisible, people may disbelieve their existence, negatively affecting behaviors related to optimal food and hygiene habits. Food preparation actions to prevent foodborne contamination include thorough initial cooking and reheating of food, in terms of both temperature and time; limiting the time cooked food is stored at ambient temperature to less than 4 h; washing utensils; and handwashing with soap before and during food preparation and before feeding children [
6,
7]. The transfer of pathogens into prepared meals is exacerbated by a lack of thoroughly washing contaminated hands after defecation of the child and caregiver, and after cleaning areas and items touched by child feces, as well as the lack of cleaning utensils used before, during and after meal preparation [
8]. Some barriers preventing cleaning are difficult-to-clean household surfaces water scarcity [
9]. Food can become contaminated through high ambient storage temperatures, lack of refrigeration, poor food storage facilities, environmental fecal contamination, and too low temperature. Cooking fuel scarcity may lead to not thoroughly cooking and reheating food [
9‐
11]. Women may not prioritize optimal hygienic food preparation and safety because of otherwise heavy workloads, poor or inadequate knowledge and ways to share about the importance of safe hygiene, correct sanitation, and hygienic food preparation practices [
10]. Focusing on food hygiene practices that involve certain measures necessary for the safety of food from production to consumption can contribute to addressing these factors.
Poor sanitation is associated with the transmission of diarrheal diseases such as cholera and dysentery, typhoid, intestinal worm infections, and polio. Inadequate food hygiene is considered a major contributor to the transmission of enteric pathogens, though good estimates of the contribution of foodborne diarrheal infections and other downstream sequelae are not available [
11,
12]. Diarrhea is one of the most important infectious disease determinants of stunting and is a leading cause of child mortality and morbidity worldwide, accounting for 8% of all deaths among children under 5 [
13,
14]. Yet even asymptomatic infection can lead to environmental enteropathy, resulting in growth shortfalls [
15,
16]. Since patients will be requested to use antibiotics when suffering from diarrhea infections, the frequent use of antibiotics can contribute to antimicrobial resistance [
17]. Environmental enteropathy leaves children chronically fighting low-grade infection due to continued exposure to enteric pathogens through poor sanitation conditions. This exhausts children’s nutrient supply from their diet, impeding physical growth and development [
18,
19].
Stunting remains an important public health issue in low and middle-income countries, especially in Sub-Saharan Africa [
13,
20‐
24]. In 2014, Kenya had a 26% rate of stunting in children under 5, and the highest stunting rate of 34% in children 18–24 months; [
25] the Government of Kenya has targeted a reduction of stunting rate to 14.7% by 2030 [
26]. Through devolution and partnerships with non-governmental organizations, private sector and civil societies, Kenya has worked to strengthen the systems that ensure sufficient water and sanitation service delivery to improve well-being of its residents [
27]. The country has supported development and implementation of guidelines targeting water, sanitation, hygiene and nutrition interventions [
28]. The cycle of chronic under-nutrition and infection, often manifesting as stunting, can have major implications for long-term health and development, including learning difficulties, language domains, social-emotional functioning, physical well-being, and barriers to community participation [
29‐
31]. Stunting is largely irreversible after the first 1000 days, leading to an intergenerational cycle of poor growth and development [
32]. The first 1000 days- the period from conception to the child’s second birthday, is a crucial period for optimum health, growth, and neurodevelopment [
33]. Women who were stunted in childhood remain stunted as adults and tend to have stunted offspring [
14,
32] .
Interventions that combine knowledge with behavior change theories and techniques have been effective at changing behaviors related to food hygiene in high-income countries [
10,
34]. However, few studies have focused on efforts on how to improve food hygiene behaviors in household environments in low-income settings [
35]. Approaches like Hazard Analysis Critical Control Point (HACCP), which identify points where control measures would be effective to facilitate appropriate targeting of resources, and the Risk, Attitude, Norms, Ability, and Self-Regulation (RANAS) model which assesses contextual and psychosocial factors associated with food hygiene practices, among others, have been used [
10,
36‐
38]. A prior study in Kenya applied Behavior Centered Design (BCD) to an intervention; BCD posits that behavior change is likely if an intervention can change the behavioral setting and cognitive processes associated with that behavior [
35]. These interventions focused on specific behaviors of interest and how they contribute to food hygiene practices but have inadequately shown the interaction and influence of the combined food hygiene practices. Although these studies were conducted in peri-urban and rural communities and were successful in improving food hygiene practices of interest; their focus was limited to specific behaviors in parts, including cooking and reheating food, cleaning utensils, and handwashing, but not multiple food preparations and hygiene practices. These studies assessed the psychological factors and emotional motivators, [
10,
11,
33] however, they did not often assess how opportunity factors could inhibit behaviors. While capability and opportunity gaps to practice food hygiene behaviors have often been reported, studies did not clarify how these could be overcome [
39,
40].
Using the Capabilities, Opportunities, and Motivation to Behavior (COM-B) model that explored the barriers to and facilitators of optimal food hygiene and preparation practices, this study reports the formative process that informed a Catholic Relief Services (CRS) funded THRIVE II program. The goal of THRIVE II was to create a culture of care and support for HIV- and AIDS-affected children under 2 (CU2) and their caregivers in Kenya, Tanzania, and Malawi by providing ongoing support to caregivers of CU2 to practice early childhood stimulation, positive parenting, optimal infant and young child feeding, and water, sanitation and hygiene (WASH) behaviors [
41]. In 2016, CRS partnered with Emory University and Uzima University (Kenya) to design an integrated WASH and nutrition behavior change intervention to be nested within a selection of THRIVE II communities to decrease stunting among CU2 [
7,
41,
42]. To inform this intervention, we conducted qualitative research between August and December 2016 with caregivers of CU2 in Migori and Homa Bay counties, Western Kenya [
7,
42,
43].
This study applied a theory-informed approach to explore the drivers and barriers to optimal food preparation and hygiene practices among caregivers of CU2 in Western Kenya. Our findings aim to inform the development of targeted improvements to a Care Group model an approach that uses a cadre of paid workers as facilitators, who impart knowledge and training to groups of ~ 12 volunteers (the Care Group); each volunteer is responsible to share the same knowledge and training with 10–15 local households [
44] intervention in Western Kenya [
41,
42].
Methods
Study sites and population
This research took place in six communities in Migori and Homa Bay counties that were participating in THRIVE II. The THRIVE II program was an early childhood development (ECD) program led by Catholic Relief Services (CRS) and local implementing partners, Homa Hills Community Development Organization (HHCDO) and Mercy Orphans Support Group (MOSGUP). The THRIVE II program continued and improved on previous CRS programming, THRIVE. THRIVE II aimed to support children in reaching their developmental milestones. Specifically, THRIVE II used the care group model to target children particularly at risk of not receiving ECD services because of poverty and HIV [
45]. Homa Bay and Migori counties were covered by THRIVE II since they had the highest HIV prevalence in Kenya in 2016; in 2017, HIV prevalence in Homa Bay and Migori were 20.7% and 13.3% respectively, far higher than the national prevalence of 4.9% [
46].
We purposively sampled THRIVE II participants for participation in the qualitative research from six health facility catchments (
N = 3, Migori county;
N = 3, Homa Bay county) in 2016. Preference was accorded to communities with variability in the agro-ecological zone, distance to the nearest health facility, and distance to the nearest urban center [
7]. Participants were recruited from THRIVE II communities which had a minimum of six women that lived near the health facilities and were either pregnant or had CU2. Recruited religious and community leaders were identified by CRS, based on their knowledge and experiences of their specific communities. The community health workers and community health volunteers recruited for participation were based in the health facility catchment area.
Theoretical approach
The Capabilities, Opportunities, and Motivations to Behavior (COM-B) model was used to guide the prioritization and analysis of barriers and facilitators to optimal food preparation and hygiene practices. The COM-B model is used to identify and understand determinants of behaviors and what needs to be altered to facilitate behavior change. The COM-B model focuses on three essential determinant domains necessary for practicing specific behaviors: capability, opportunity, and motivation (Table
1). The COM-B model posits that both capability and opportunity are prerequisites for motivation: people must have the physical and psychological capability to perform the behavior, the physical and social opportunity to do the behavior, and the automatic and reflective motivation to practice the behavior over other competing priorities [
7].
Table 1
Capability, opportunity, motivation, and behavior definitions [
47]
Capability | Capability is an attribute of a person that together with opportunity makes a behavior possible or facilitates it |
Psychological capability | A capability that involves a person’s mental functioning (e.g. understanding and memory) |
Physical capability | A capability that involves a person’s physique and musculoskeletal functioning (e.g. brain and extremity) |
Opportunity | An attribute of an environmental system that together with capability makes a behavior possible or facilitates it |
Social opportunity | An opportunity that involves other people and organizations (e.g. social and cultural norms) |
Physical opportunity | An opportunity that involves inanimate parts of the environmental system and time (e.g. financial and material resources) |
Motivation | All brain processes that energize and direct behavior |
Reflective motivation | The motivation that involves conscious thought processes (e.g. evaluations and plans) |
Automatic motivation | The motivation that involves habitual, instinctive, drive related, and affective processes (e.g. desires and habits) |
We categorized the barriers and facilitators to food preparation and hygiene practices based on COM B framework. We mapped these determinants to five mealtime behaviors which necessitate optimal food preparation and hygiene practices- food preparation and handling practices that have the potential to minimize contamination of food by pathogenic organisms. We provided operational definition of these behaviors.
Data collection
Qualitative data were collected from October to December 2016 using focus group discussions (FGDs), key informant interviews (KIIs), and household observations. Seven research assistants from communities in western Kenya were trained over two weeks on qualitative research methods, research ethics, and data management prior to data collection. Training of the research assistants was conducted by the field team manager, a Kenyan native (EAO), with the support of a research manager from Emory University (AE). Qualifications of research assistants were: 1) Fluent Luo, Kiswahili, and English speakers; 2) experience in qualitative data collection; and 3) understanding of the study area. Kenya CRS personnel and research assistants provided input on adaptations to translation, cultural appropriateness, and length of tools (FGD and KII guides, observation checklist). Research tools were piloted with THRIVE II participants and community health workers in Migori County, researchers provided feedback to adjust tools to improve clarity and focus on thematic domains.
Focus group discussions
We conducted 24 FGDs with: pregnant women and mothers (
N = 12), fathers (
N = 6), and grandmothers (
N = 6) of CU2 to understand their practices related to food hygiene and preparation. All participants had to be 18 years or older, and a caregiver for a child between the ages of 1-and 24 months, or a woman who identified as pregnant. Women who identified as pregnant and mothers of CU2 were selected based on their participation in THRIVE II; grandmothers had to have at least one grandchild under two years; fathers had to have at least one child under two years and were related to the THRIVE II participants [
7]. Since programming was to take place over two years, pregnant women were included as they would eventually be caregivers of CU2, and their nutrition and WASH behaviors during pregnancy could affect the infant’s growth and development [
48]. Six to eight participants were recruited by implementing partner members for each focus group, based on their availability and willingness to participate; 139 total participants were engaged. Keeping FGD participant numbers from six to eight provided time and opportunity for each participant to engage in the discussions.
We conducted more FGDs with mothers as primary caregivers; grandmothers and fathers were included as they may be primary or secondary caregivers, and their support, knowledge, availability, and practices can influence the behavior of the mothers. FGDs with pregnant women and mothers of CU2, and grandmothers focused on nutrition, feeding, and WASH and FGDs with fathers focused on WASH. FGDs with pregnant women, mothers and grandmothers were facilitated by female research assistants and were held in community churches or health facilities.
A total of 29 KIIs were conducted with religious and community leaders (N = 11), community health workers (N = 5), community health volunteers (N = 6), and THRIVE II staff and implementing partner staff (N = 7) to understand what influences food hygiene and preparation, infant and young child feeding practices, and intervention implementation. The key informants identified the determinants of community infant and young child feeding (IYCF) and WASH behaviors, based on their roles and responsibilities in encouraging optimal behaviors, leading to their recommendations for programming. CRS staff and implementing partner staff reported on the goals of THRIVE II and program outcome design.
Observations
In each of the six study communities, we conducted observations with 12 households. We conducted two observations per household for a total of 24 structured household observations. The research assistants and the community health volunteers (CHVs) worked together to identify households based on the following criteria: 1) a female caregiver participating in THRIVE II who had consented to observation, and 2) had an index child (6–24 months) as the primary focus. We received consent from mothers as they were identified as primary caregivers. If other caregivers (siblings, grandparents, fathers, etc.) were present or caring for the child, that information was included in the observation. An ‘index child’ was selected as the focus of observation as some households had more than one child between 6 and 24 months of age. Observations were conducted in Luo by research assistants who were residents of Homa Bay and Migori counties. Observations were conducted over two days by the same researcher in the same household; 4 h on day one, and 6 h on day two, to understand caregivers’ behaviors. Caregivers who participated in observations did not participate in FGDs. Caregivers were fully aware of being observed and were encouraged to continue with their activities as they would do in the absence of the observer. The use of two days of observations in the same household by the same observer was intended to minimize reactivity bias and to increase caregiver comfort in the presence of the observer. Half of the observations were conducted in households with an index child between 6-and 12 months, and half with an index child aged between 13-and 24 months. Research assistants used a structured observation tool to record food hygiene behaviors related to meal preparation, feeding, hygiene, sanitation, water collection, and handwashing. Research assistants also conducted household spot checks to assess the compound environmental sanitation and sanitation hardware (e.g. presence of handwashing station near food preparation area, presence of animal feces in food preparation areas, functionality and use of latrine). Observations were intended to give insights into IYCF and WASH behaviors that caregivers of CU2 practiced at home. Caregivers with children of different ages were targeted to enable observation of potential differences in hygiene behaviors.
Observations were conducted between 09:00 and 16:00 h; 09:00 was the earliest time that care group volunteers (lead mothers who spread basic health information to a maximum of 12 women or families in their communities) [
49] would accompany research assistants to households. Caregivers usually granted permission for observations over their midday meal, enabling the research assistants a chance to observe their food preparation and hygiene practices. In the event that a caregiver expressed discomfort or refusal to be observed during food preparation, observers respected their decision.
Data management and analysis
Focus group discussions (FGDs) were conducted in Luo, while key informant interviews (KIIs) were conducted in the language of the participant’s choosing- either Luo, Kiswahili or English, and audio-recorded. The FGD and KII audio files were uploaded to a cloud-based server, de-identified, transcribed verbatim in Luo and translated into English. Back translation of the transcripts was not done; however, transcripts were reviewed against corresponding audios by the field team managers to ensure the accuracy of translations. Detailed field notes from household observations were written in English and typed into Word documents. All individual files were password protected.
Data analysis began concurrently with data collection. The field team debriefed daily, discussing the emerging themes from the day’s data collection. Detailed daily briefing notes were maintained and shared with the research team via the cloud-based server. Thematic analysis [
50,
51] was used to identify common barriers and facilitators to the targeted behaviors, including food preparation and hygiene, and developed these into a codebook. Through the use of the COM-B model (Table
1) of behavior change and behavior change wheel framework, deductive codes were developed and aligned to specific behaviors of interest and key behavior determinants – capability, opportunity, and motivation [
47]. KII and FGD transcripts were then coded using MAXQDA v20.1.1. Four researchers met weekly to discuss iterations to the codebook and ensure that they had the same understanding and coded similarly. Ambiguous segments were discussed, and codes were adapted as needed. Observation data from the checklists were analyzed using Microsoft Excel, and observation notes were thematically analyzed, identifying common themes and patterns.
Ethics
The research protocol was reviewed and approved by the Great Lakes University of Kisumu Research Ethics Committee (Kisumu, Kenya) (#GREC/1954/2017), the Government of Kenya National Commission for Science, Technology, and Innovation (Nairobi, Kenya) (NACOSTI/P/16/72200/13631), and Emory University’s Institutional Review Board (Atlanta, GA) (#IRB00090057). Research assistants read the informed consent to the participants in Luo. All participants provided written informed consent after it was read to them.
Discussion
This study explored facilitators and barriers to practicing optimal food preparation and hygiene behaviors (Table
5) in Homa Bay and Migori Counties in western Kenya. The behaviors of interest on focus were 1) handwashing, 2) washing food, 3) cooking and reheating food, 4) cleaning utensils and protecting food preparation spaces, and 5) covering and storing food. The identified facilitators and barriers were categorized by the COM-B domain to better understand the relationships between the determinants; our ultimate objective was to develop and test a theory-informed intervention [
41,
42]. Several critical barriers emerged from our data especially related to physical opportunity including resources and facilities and social opportunity such as sociocultural norms. These barriers, compounded with poverty and high HIV prevalence within the study population could have a major implication on hygienic food preparation practices. While many caregivers demonstrated knowledge and skills, had resources/facilities, and were motivated to practice most food preparation and hygiene practices, others lacked knowledge and skills (capability) to practice certain food preparation and hygiene behaviors, namely, prolonged food storage in an unsafe environment. Many caregivers lacked resources (opportunity) like soap, water, firewood, and time to practice safe food preparation and hygiene practices. Socio-cultural norms related to handwashing, washing, reheating, and covering food also hindered optimal food preparation and hygiene behaviors. Leveraging existing facilitators (knowledge and available resources) to address specific barriers to practicing food hygiene and preparation behaviors can increase people’s motivation to enact specific behavior through encouraging continuity of positive practices. Experiences and recommendations from previous intervention programs aligned with our findings [
10,
11,
53]. Based on this formative work, we recommend that programs that aim to address food preparation and hygiene practices (Table
5) utilize theory informed approaches to inform their interventions, considering the context in which the interventions are implemented. This study highlighted how determinants to food preparation and hygiene behaviors were influenced by capability, opportunity and motivation and how these domains had an influence in part or whole to achieving the optimal food preparation and hygiene behaviors in this setting.
Table 5
Definitions of optimal food preparation and hygiene behaviors [
41,
52]
Handwashing | Handwashing with soap and water by the caregiver and the child at critical times (before eating; before feeding child; before, during and after food preparation; after defecation of caregiver and/or child; after cleaning area/tools for child defecation) |
Washing food | Washing of fruits and vegetables before eating |
Cooking and reheating food | Cooking of food until boiling/very hot; reheating left-over food to appropriate temperature (until very hot) before eating or feeding the child |
Cleaning utensils and food preparation surfaces | Washing and drying of utensils and food preparation surfaces after use Food preparation space cleanable, inaccessible to animals and elevated off the floor Utensils stored dry, free of dirt and debris, and inaccessible to animals and children |
Covering and storing food | Food covered after it is removed from fire. Food inaccessible to animals, children, and flies. Storing food at ambient temperature for no more than 4 h |
Capability
A minority of caregivers lacked knowledge on the critical times for handwashing, skills on washing food, drying utensils, covering food, and storage of food, similar to studies in rural Malawi and Nepal [
10,
11,
54]. Children’s hands were not washed as often as adults’ hands and in most cases, soap was not used. Previous interventions have targeted the promotion of food hygiene behaviors through different information, education, and communication (IEC) strategies. Intervention implementation on food hygiene in Malawi and Vietnam used IEC strategies like demonstrations, games, rewards, songs, workshops, newsletters, loudspeaker announcements, and flip chart communication to create awareness and educate people on food hygiene practices [
37,
55]. In Pradesh India, Tidwell et al. found that targeted messages through television commercials or messages delivered via mobile phones produced a significant increase in handwashing behavior among mothers [
56]. Although some interventions already exist that focus on measures to increase knowledge and skills on food hygiene practices, these interventions may need to be more targeted. For instance, interventions that address handwashing at critical times may need to lay more emphasis on the importance of training children on handwashing at critical times, even if the hands are not visibly dirty, to instill the habitual practice as they grow. Additionally, visual forms of education which portray the presence of germs on people’s hands could be used to facilitate peoples’ understanding on reality of invisible germs.
Opportunity
Practicing behaviors requires an enabling physical environment: resources, time, and social norms (physical and social opportunity), and these were both enablers and barriers to practicing food hygiene behaviors. Evidence suggests that barriers to physical resources negatively impact food hygiene behaviors [
12,
39]. Data from this study revealed that some caregivers lacked materials, this aligned with literature that reported a similar lack of critical materials (soap, water, firewood, time, handwashing station near food preparation area, and cues to trigger action) that contribute to not practicing food preparation and hygiene behaviors [
11,
39,
40]. In food hygiene studies in Nepal and India, participants in FGDs reported practicing handwashing using soap, but observations revealed a lack of use of soap for handwashing [
10,
57]. Although disconnect exists on practices reported to practices observed, handwashing is a common practice, and is an indication that handwashing with soap may be a particularly acceptable and feasible practice to target through targeted handwashing messaging [
35,
58]. In Kenya, a study reported a substantial increase in the presence of soap and water together within 10 m of the food preparation area after intervention implementation [
42]. Changes to physical and social opportunity have been addressed in interventions by the WASH Benefits study and the Safe Start trial. In these intervention trials, caregivers received handwashing stations, soap, food storage containers; and education and motivational messaging thus demonstrating improved knowledge and practice on proper food hygiene practices [
58,
59]. Although the WASH Benefits trial reported insignificant reduction in diarrhea after intervention implementation in Kenya, the researchers also noted inconsistent promoter support [
58]. Support from community health workers through existing groups like neighbor groups within the care group model have demonstrated adoption of food hygiene and preparation practices [
42]. Education combined with provision of infrastructure in addition to consistent and continued CHV support, may facilitate hygienic food preparation practices.
The availability of infrastructure is a strong indicator of the successful performance of desired targeted behavior [
37,
39,
60]. In Kenya, the Ministry of Public Health and Sanitation has regulations on drying racks, and as part of THRIVE II, an emphasis on food hygiene practices had been placed on washing and drying utensils using a drying rack placed in the sun, however, many households in our study communities lacked one. Caregivers had developed innovative approaches, which included the utilization of alternatives (crates, buckets) that facilitated the drying of utensils, a clear indication that solutions to some of these challenges exist within communities and recognizing such is key. Programs that implement interventions related to food hygiene in communities may need to identify existing innovative approaches within these communities and integrate them into their planned interventions implementation.
Social cues and cultural norms (social opportunity) were major barriers to food preparation and hygiene practices [
61]. Food preparation in large quantities was a common practice due to lack of time, competing demands, and cultural norms. Prioritization of tasks to address time and work demands could be achieved through task-sharing among household members. In South Africa and Kenya, studies incorporated fathers and grandmothers in maternal and child nutrition practices and reported the contribution of fathers in decision making, in addition to expressing a preference for being more involved in maternal and child nutrition and care practices; and grandmothers providing childcare, nutritious food, and social support to mothers [
62,
63]. Interventions could employ such strategies in communities where women bear the most burden of working and taking care of children like in communities in our context, to relieve them of some burden, and focus on food hygiene and preparation practices.
In our study areas, foods were stored uncovered due to the belief that they would spoil, and this could also be dependent on knowledge of food spoilage [
42]. Some of the barriers to food storage could be addressed through the use of current technology for instance refrigeration. However, in this context, other factors like lack of electricity and affordability (cost) can hinder embracing technology, making it more challenging to address such beliefs. Some interventions have employed both interpersonal counseling and a community-based approach to sensitize communities with targeted messaging [
42,
55]. Within the context of this study, sensitization of community educators and religious leaders and further engagement of community health volunteers to facilitate behavior change messaging could be employed.
In our study communities, women were involved in household responsibilities that required resources (physical opportunity), but they lacked monetary decision-making powers that would enable them to acquire resources, and this influenced their ability to prioritize tasks. Food hygiene interventions that have utilized a whole household-based approach have been effective at addressing barriers to food hygiene and preparation practices [
53]. In particular, in Burkina Faso, gender-inclusive approaches reduced the workload and increased monetary decision-making power for women [
64]. Labor-saving technologies that allow for utilization by both men and women, for instance, improving household water sources, use of alternative fuels or improved stoves, and awareness-raising for both men and women on hygiene could increase gender inclusivity [
65]. Care for children, especially feeding is viewed as a collective responsibility to mothers, grandmothers, siblings, and sometimes neighbors, a finding that has been reported in other low-income settings [
40,
66]. In western Kenya, interventions that targeted male involvement with decision-making on complementary feeding, and grandmothers’ involvement in the provision of positive social support improved some infant feeding practices [
53,
63,
67]. Additionally, relieving women from taking up all the household responsibilities through task shifting, role sharing, training other household members including fathers, siblings, and grandmothers may help in improving food hygiene practices in the household by allowing time to prioritize proper food hygiene practices.
Motivation
Motivation, as observed from our data, was driven by prioritization, specific routines and plans, disgust, and beliefs, and both facilitated and hindered practicing food preparation and hygiene behaviors. Motivation to enact behavior can be limited by capability and opportunity, as these two domains are prerequisites to motivation. Disgust related to visible dirt and flies facilitated handwashing, covering of food, and washing of utensils similar to reports from studies elsewhere [
39,
68,
69]. Belief that dirty hands could carry microbes that can make someone sick facilitated handwashing, although the absence of visible dirt hindered the practice. Since motivation always involves a competition between alternative behaviors, getting people to enact behavior may involve both decreasing and increasing motivation to enact behavior [
47]. In this context, the importance placed on specific practice influenced prioritization, which was also influenced by physical opportunity; for instance, distance to a water source informed how water was utilized in the household.
Our data informed a WASH and nutrition intervention grounded in the COM-B theory of behavior change. The findings were used to develop a strategy that added minimal inputs to enable behavioral change, including information, education, and communication materials (pledge cards and food hygiene cards), and hardware (washbasin, pitcher, and soap for handwashing stations and mesh food covers) [
42]. The intervention implementation based on this formative research resulted in improvement in hygienic food preparation outcomes and handwashing practices [
42]. Interventions based on culturally acceptable, locally available, and low-cost interventions have increased handwashing practices among women after involving community health workers in providing hygiene messages to mothers through household visits [
55,
70].
Acknowledgments
Catholic Relief Services was the main implementing partner. Vanessa Tobin developed an initial scoping document that outlined synergies between WASH and nutrition and supported the early stages of the project as the Chief of WASH for CRS. Catholic Relief Services: Maureen Kapiyo, David Leege, Elena McEwan, Fidelis Muthoni, Raphael Ofware, George Okoth; Emory University: Maryann Delea; Homa Hills Community Development Organization: Dennis Ochieng, Evelyne Otieno, Stephan Owino; Mercy Orphans: Tobias Ogaga, Josephine Okomo, Phenny Ogweno, Judith Wara; Uzima University: Dorothy Adhiambo, Lydia Atetwe, Lily Lukorito, Nicanor Muga, Jackline Okumu, Fredrick Okumu, Rosebella Ouda, Nancy Oyugi.
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