Introduction



9144001143000TRANSLATING THE SOCIAL ECOLOGICAL MODEL INTO RECOMMENDATIONS FOR FOOD SAFETY PROMOTION IN INDIAbyAdaobi U. NwokaBS, Howard University, 2012Submitted to the Graduate Faculty ofHealth Policy and ManagementGraduate School of Public Health in partial fulfillment of the requirements for the degree ofMaster of Public Health University of Pittsburgh201600TRANSLATING THE SOCIAL ECOLOGICAL MODEL INTO RECOMMENDATIONS FOR FOOD SAFETY PROMOTION IN INDIAbyAdaobi U. NwokaBS, Howard University, 2012Submitted to the Graduate Faculty ofHealth Policy and ManagementGraduate School of Public Health in partial fulfillment of the requirements for the degree ofMaster of Public Health University of Pittsburgh2016 center301625UNIVERSITY OF PITTSBURGHGRADUATE SCHOOL OF PUBLIC HEALTHThis essay is submittedbyAdaobi NwokaonApril 10th, 2016and approved byMargaret A. Potter, JD, MS______________________________________ProfessorHealth Policy and ManagementAssociate Dean for Public Health PracticeGraduate School of Public HealthUniversity of PittsburghJoanne Russell, MPPM______________________________________Assistant ProfessorBehavioral and Community Health ScienceDirector, Center of Global HealthGraduate School of Public HealthUniversity of Pittsburgh00UNIVERSITY OF PITTSBURGHGRADUATE SCHOOL OF PUBLIC HEALTHThis essay is submittedbyAdaobi NwokaonApril 10th, 2016and approved byMargaret A. Potter, JD, MS______________________________________ProfessorHealth Policy and ManagementAssociate Dean for Public Health PracticeGraduate School of Public HealthUniversity of PittsburghJoanne Russell, MPPM______________________________________Assistant ProfessorBehavioral and Community Health ScienceDirector, Center of Global HealthGraduate School of Public HealthUniversity of Pittsburghcenter4648200Copyright ? by Adaobi Nwoka201600Copyright ? by Adaobi Nwoka2016ABSTRACTcenter-222250Margaret A. Potter, JD, MS TRANSLATING THE SOCIAL ECOLOGICAL MODEL INTO RECOMMENDATIONS FOR FOOD SAFETY PROMOTION IN INDIAAdaobi Nwoka, MPHUniversity of Pittsburgh, 201600Margaret A. Potter, JD, MS TRANSLATING THE SOCIAL ECOLOGICAL MODEL INTO RECOMMENDATIONS FOR FOOD SAFETY PROMOTION IN INDIAAdaobi Nwoka, MPHUniversity of Pittsburgh, 2016Foodborne illnesses are a burden on public health and contribute significantly to the large numbers of mortality and morbidity in India. Common forms of foodborne diseases in India are due to bacterial contamination of foods. Foodborne illnesses are also a preventable and underreported public health problem.?Currently, there is no national foodborne disease surveillance system available to enable effective detection, control and prevention of foodborne disease outbreaks. ?In addition, progress in Indian infrastructure has been painstakingly slow in recent years.?Despite these challenges, the Government of India enacted the Food Safety and Standards Act in 2006 as a form of public health promotion in the area of food safety. Unfortunately, policy-making in India has frequently been characterized by a failure to anticipate needs, impacts, or reactions, which could have reasonably been foreseen, thus impeding economic development. India's policymaking structures have difficulties formulating the "right" policy and adhering to it. Hence, refining the policy-making competence of India’s senior civil servants and the elected officials in Government may improve the structure involved in public policy-making in India. Furthermore, coordination can be achieved by addressing social ecological factors in pursuit of behavioral changes. Other actions to further evidence-based policy include preparing and communicating data more effectively, using existing analytic tools, conducting policy surveillance, and tracking outcomes with different types of evidence.Keywords: Food Safety, Safe Food Practices, India Food Safety Policy, Social Ecological Model, Social Determinants of Health, Challenges in Rural Marketing, Food Safety Strategies, Food Safety Campaigns, Media and Food SafetyTABLE OF CONTENTS TOC \o "2-4" \h \z \t "Heading 1,1,Appendix,1,Heading,1" List of acronyms PAGEREF _Toc448930433 \h xpreface PAGEREF _Toc448930434 \h xi1.0Introduction PAGEREF _Toc448930435 \h 11.1public health relevance PAGEREF _Toc448930436 \h 32.0chapter one: The Demographic Overview of India PAGEREF _Toc448930437 \h 42.1The Demographical Context of India PAGEREF _Toc448930438 \h 42.2Historical Framework of India PAGEREF _Toc448930439 \h 62.3Politics in India after Independence PAGEREF _Toc448930440 \h 72.4Role of the Government in Public Health PAGEREF _Toc448930441 \h 92.5The Food Safety and Standards Act of India PAGEREF _Toc448930442 \h 113.0chapter two: the application of the social ecological model to health behavior PAGEREF _Toc448930443 \h 143.1The Principles of the Social Ecological Model PAGEREF _Toc448930444 \h 143.2Understanding Multi-Level Influences on Food Safety PAGEREF _Toc448930445 \h 164.0chapter three: a multilevel approach to food safety in the framework of the social ecological model PAGEREF _Toc448930446 \h 214.1Translating Social Ecological Model into Recommendations for Food Safety Promotion PAGEREF _Toc448930447 \h 235.0recommendations PAGEREF _Toc448930448 \h 30APPENDIX: THE FEDERAL STRUCTURE OF THE REPUBLIC OF INDIA PAGEREF _Toc448930449 \h 34bibliography PAGEREF _Toc448930450 \h 35List of tables TOC \h \z \c "Table" Table 1. Key Findings of the WHO Survey of Street Vended Foods PAGEREF _Toc448930451 \h 18List of figures TOC \h \z \c "Figure" HYPERLINK \l "_Toc448930452" Figure 1. Social Ecological Model Levels PAGEREF _Toc448930452 \h 16Figure 2. Edgar Dale, Cone of Learning PAGEREF _Toc448930453 \h 28List of acronymsAcronymDefinitionAYUSHAyurveda, Yoga and Naturopathy, Unani, Siddha and HomeopathyBAHABelize Agricultural Health AuthorityFBOFood business OperatorsFSSFood Safety and StandardsFSSAIFood Safety and Standards Authority of IndiaFSOFood Safety OfficersGWPGlobal Water PartnershipHACCPHazard Analysis Critical Control PointHIVHuman Immunodeficiency VirusIUWMIntegrated Urban Water ManagementLMICLow and middle income countriesMOHFWMinistry of Health and Family WelfarePFAPrevention and Food AdulterationSEMSocial Ecological ModelWAPCOSWater and Power Consultancy ServicesWHOWorld Health OrganizationprefaceThis essay is in partial fulfillment of the requirements for the degree of Master of Public Health. It brings me great joy to compose a paper that highlights my interests in public health. I hope this paper will stimulate research in the area of food safety. Several people played an important part in accomplishing this submission. I would like to especially acknowledge the essay advisors of this paper for their excellent job in reviewing and providing high-quality recommendations. IntroductionOver the years, diarrheal disease has been a serious health hazard for adults and children in India.1 In 2005, it was reported that 1.8 million people died from diarrheal diseases largely due to contaminated food and water.2 Scientific studies have investigated outbreaks from 1980-2009 of foodborne diseases in India and indicated that a total of 37 outbreaks involving 3,485 persons were due to food poisoning.3 In 2008, diarrheal disease remained one of the top leading causes of death in India with an estimated 1,181 per 100,000 deaths.1 The estimated diarrheal disease mortality due to foodborne infections in India is still unknown; however, isolating foodborne sources is a critical step towards defeating a disease that is preventable. In 2006, the Indian state government launched the Food Safety and Standards Act (FSS) as a fundamental part of promoting public health practice.4 The overall goal of this policy is to attain high levels of food hygiene and safety practices, which will promote health, control food-borne diseases and eliminate the risk of diseases related to poor food hygiene and safety.4 This study provides an overview of the FSS, the barriers to proper food safety practices in India and policy implementation strategies to improve compliance. The first chapter presents a demographical outlook of India and explains the significance of the FSS. The second chapter discusses the social determinants of health and their influence on compliance, by using to the social ecological model. The third chapter concludes by highlighting several complementary programs that would support the FSS act by harmonizing political, social, and economic factors. Beneficial to providing sound recommendations, it is important to evaluate this country’s profile in order to properly understand the difficulty in resolving the issue of food safety compliance in India. public health relevanceFood safety is increasingly becoming an important public health issue and great concern for India. Food businesses particularly should comply with food safety guidelines as failure to do so poses concerns for consumers. However, India is faced with many challenges including the inability to provide sufficient regulatory oversight. Moreover, time and inadequate training are cited as reasons why food service workers do not follow safe food handling practices in India.?Food safety education is an essential factor of quality control, behavior change and reducing risk of food poisoning. This essay explains the influence governmental officials and society have on food safety, as well as multi-level strategies aimed to support the enacted Food Safety and Standards Act. chapter one: The Demographic Overview of IndiaThe Demographical Context of IndiaIndia is a country with multifaceted cultures and varied socio-economic and cultural backgrounds. India is located in the southeastern part of Asia and is surrounded by Bangladesh, Bhutan, Burma, China, Nepal, and Pakistan.5 As of 2015, India is currently home to approximately 1.3 billion. 5 The urban and rural populations of India make up 32.7% and 67.3% respectively.5 Hindi is the most widely spoken language and primary tongue of 41% of the people; however, there are 14 other official languages: Bengali, Telugu, Marathi, Tamil, Urdu, Gujarati, Malayalam, Kannada, Oriya, Punjabi, Assamese, Kashmiri, Sindhi, and Sanskrit.5 Research has shown language barriers significantly affects access to care, causes problems of comprehension and adherence, and decreases the satisfaction and quality of care.6 The internal migration across state borders over the past two decades has led to the increase in health workers encountering instances of language discordance, which makes it difficult to communicate with patients.6 Over the past several decades, India has been witnessing an increase in the population, literacy, urbanization, chronic diseases and other changes in disease patterns.5 The overall life expectancy in India has increased significantly over the past two decades from 58 years in 1990 to 66 years in 2013.5 This is a result of improved public health programs and policies, economic infrastructure and lower mortality rates over time. Although India is experiencing increasing deaths due to chronic diseases, it is noteworthy to point out that deaths related to infectious disease remain a pressing issue in India.7 In 2014, 60% of deaths were due to chronic diseases, however infectious diseases accounted for 28% of deaths in the population.7 Infectious diseases in India are related to poor sanitation, contaminated food, inadequate personal hygiene, access to safe water and lack of basic health services.8?Rural areas in India report more deaths due to communicable, maternal, perinatal and nutritional conditions than urban areas.8 This is due to large-scale poverty, developmental disparities between states, greater gender discrimination and disproportionate healthcare resources.9 These factors contribute enormously to the challenges of integrating proper health practices. For example, women are largely excluded from making decisions, have limited access to and control over resources, restricted mobility, and are often under threat of violence from male relatives.10 Other key challenges in healthcare include imbalanced resource allocation, limited physical access to quality health services, and behavioral factors that affect the demand for appropriate health care.11In 2013, the total health expenditures was 1.3% of India’s GDP, which is below the low and middle-income countries (LMIC) average of 5.3%. 5,12 Most importantly, out of pocket expenditures were 67%, which is much higher than the LMIC average of 44%. 12 In addition, health insurance has only covered 5% of Indians. As a result, over 20 million Indians are pushed below the poverty line every year because of the effect of out of pocket spending on health care.12 Currently, 29.8% of Indians live below the poverty line, with 23.6% of those within the poverty line living on less than $1 USD a day. 13Historical Framework of IndiaUntil its independence in 1947, neighboring countries of India today including Pakistan, Bangladesh (formerly East Pakistan), Myanmar (formerly Burma) were all parts of British India and were all considered as India.37 Over the years, there has been some debate about the official date India earned its independence from the British. In accordance with the India Independence Act of July 18, 1947, the Union of India and Pakistan were partitioned from the former “British India” that had been a part of the Parliament of the United Kingdom.37 However, the British army officially left India in 1950 and India's first constitution was written shortly thereafter on January 26, 1950, which officially declared it a member of the British Commonwealth.37 Therefore, the Indians celebrate January 26, 1950 as the Republic Day of India.37The direct administration by the British, which began in the mid 1800s, effected a political and economic unification of the subcontinent.37 When British rule came to an end in 1947, the subcontinent was divided along religious lines into two separate countries—India, with a majority of Hindus, and Pakistan, with a majority of Muslims.37 As a result, India remains one of the most ethnically diverse countries in the world.37 Apart from its many religions and sects, India is home to innumerable castes and tribes, and many spiritual groups, including Muslims, Christians, Sikhs, Buddhists, and Jains.37 Earnest attempts have been made to infuse a spirit of nationhood in such a varied population, but tensions between these groups have remained and at times have resulted in outbreaks of violence.37 Nevertheless, many social legislations have attempted in alleviating the inequality occurring among formally castes, tribal populations, women, and other traditionally disadvantaged segments of society.37Politics in India after Independence The official name of the Indian government is Union Government of India.14 The Indian government is a parliamentary system of democratic governance.14 The government of India is the governing authority of 29 states and 7 union territories of the country as per the Constitution of India.14 The Constitution of India is federal, but contains a strong central government, which holds both extensive emergency powers and residuary powers from the Union.14 Similar to the United States system, the 29 states function autonomously in general, but the central government retains the decisive power to control and direct the administration of states under certain conditions.14 As Paul Brass, the author of the Politics of India since Independence noted in 1990…The Constitution of India made a sharp break from with the British colonial past, though not with British colonial practices. The Constitution adopts in total a Westminster form of parliamentary government rather than a mixed parliamentary-bureaucratic authoritarian system, which is actually exists in India. (Brass, 1994, pg. 5)Currently, the central government of India is comprised of three distinctive branches, which includes the Executive, the Legislative and the Judiciary branches.15 The Executive Branch involves the President, the Vice President, the Prime Minister and the Cabinet Ministers of India.15 The Executive branch of the nation's government is entirely responsible for the daily administration of the bureaucracies of the diverse states and union territories of India.15 The Legislative branch is commonly known as Parliament, which consists of the two Houses of People, the Rajya Sabha and the Lok Sabha.15 The members of the legislative government have many responsibilities; however, this essay will focus mainly on the obligation of the Prime Minister and the Council of Ministers for any policy failure within the government.15, 16 In terms of Article 74(1) in the constitution, the President is compelled to have a Council of Ministers with the Prime Minister at the head.15 The President appoints the Prime Minister while all other council ministers are appointed by the President with the advice of the Prime Minister.15 Although the term “Cabinet’ is absent in the constitution, the Cabinet ministers consists of the senior ministers to whom the Prime Minister consults in arriving at policy decisions.15,16 Based on the constitution, the Parliament is the nation’s supreme law making body.15 However, the Prime Minister and the cabinet have a firm control over the Parliamentary majority. 44 Therefore, the Prime Minister and the Cabinet can make the Parliament pass whatever law the Prime Minister wishes the Parliament to pass.44 Conversely, the Parliament shall never pass a bill, which the Prime Minister and the Cabinet oppose.44 Thus, the law making powers of the Parliament involuntarily become the powers of the Cabinet.44 The Prime Minister and the Cabinet also have control over the nation’s finances.44 The annual budget is prepared by the instructions of the Cabinet.44 For example, the proposals for taxes and expenditures are arranged by the Cabinet then formally approved by the Parliament.44The Judiciary branch is ruled by the Supreme Court of India, which consists of High Courts and several district level courts.15 In addition to the original jurisdictions given to the Supreme Court, Article 32 of the Constitution of India provides extensive jurisdiction related to the fundamental rights enforcement.15Role of the Government in Public HealthThe Indian Constitution includes a list of directive principles of state policy that express ideals of social justice, equality, and welfare.15 For example, the constitution explicitly urges the government to establish a minimum wage, provide education and jobs for people from disadvantaged backgrounds, and improve public health.15 Although the directive principles have no legal status and cannot be enforced by the courts, they were intended to guide the government in policy-making. The role of government is especially crucial for addressing challenges and achieving health equity. Since independence, major public health problems such as tuberculosis, high maternal and child mortality and human immunodeficiency virus (HIV) have been addressed through intensive actions of the government.17 The Ministry of Health and Family Welfare (MOHFW) plays a key role in guiding India's public health system. The MOHFW holds cabinet rank as a member of the Council of Ministers and composed of four departments: Health & Family Welfare; Health Research; AIDS Control; and Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH). 17The MOHFW is primarily responsible for health policy and family planning programs. 17 In addition MOHFW is responsible for ensuring safe food to the consumers.19 In the past, several States formulated their own food laws, however there was a considerable variance in the rules and specifications of the food that interfered with inter-provincial trade.19 Consequently, the Prevention of Food Adulteration (PFA) Act of 1954 was enacted in June 15, 1955 to ensure pure and wholesome food to the consumers and also to prevent fraud or deception.18 The PFA Act has been amended thrice in 1964, 1976 and in 1986 with the objective of closing the loopholes, making the punishments more stringent and empowering consumers and voluntary organizations to play a more effective role in its implementation.18,19 The PFA Act repealed all laws, existing at that time in States concerning food adulteration.18,19 Despite the noble attempt of the government to address issues related to food adulteration, food contamination persisted, which captured the attention of policymakers.The Food Safety and Standards Act of India As previously noted, in 2013 diarrheal diseases remained one of the leading causes of preventable deaths in India with an estimated 1,181 per 100,000 deaths.1 Despite many challenges in formulating an effective food safety policy, these policies have been refined over the last decade by the Council on Ministers. The Government of India enacted this comprehensive act in 2006 to enforce a training and awareness program on food safety for food business operators (FBOs), regulators, and consumers.20 The Act also aims to establish a single reference point for all matters relating to food safety and standards, by moving from multi-departmental control to a single line of command.4 In other words, the Act established an independent statutory authority to the Food Safety and Standards Authority of India (FSSAI).4 The FSSAI is an agency under administrative control of the Ministry of Health and Family Welfare.4 This agency is responsible for protecting and promoting public health through regulation of food safety.4 The FSSAI was established under the Food Safety and Standards (FSS)Act of 2006, which consolidated all statutes and regulations related to food safety in India.4 The Act states that the FSSAI must perform the following functions: Framing of regulations to lay down the standards and guidelines in relation to articles of food and specifying appropriate systems of enforcing various standards.Laying down mechanisms and guidelines for accreditation of certification bodies engaged in certification of food safety management system for food businesses.Arranging procedures and guidelines for accreditation of laboratories and notifying the accredited laboratories.Providing scientific advice and technical support to Central Government and State Governments in the matters of framing the policy and rules in areas that have a direct or indirect bearing of food safety and nutrition.Collecting and collating data regarding food consumption, incidence and prevalence of biological risk, contaminants in food, residues of various, contaminants in foods products, identification of emerging risks and introduction of a rapid alert system.Creating an information network across the country so that the public, consumers, Panchayats (local government) receive rapid, reliable and objective information about food safety and issues of concern.Providing training programs for persons who are involved or intend to get involved in food businesses.Contributing to the development of international technical standards for food, sanitary and phyto-sanitary measures.Promoting general awareness about food safety and food standards.The major downfall with this enactment are the insufficient resources and assistance made available for food businesses.21 Studies have mentioned the need for an incremental program that would train Food Safety Officers (FSO) on how to inspect, audit, and conduct food surveillance to ensure food safety and hygiene.21 However, food inspection and regulatory services are often located in major cities, with little or no control exercised in small towns and rural areas.22 Another major challenge to enforcing food safety norms in India are the insufficient number of food testing laboratories.23 Currently, the number of laboratories per million people in the country is far below other countries like China and the US.23 Even in terms of staff, most Food and Drug Administrations in India operate far below the required capacity. 23 Consequently many laboratories have been shut down due to the lack of food analysts.23In addition, the very fact that the Act extends its jurisdiction to all persons who handle food under the definition of Food Business Operators (FBOs) is a vast base to cover.4, 24 Indian FBOs range from small time street hawkers to upscale restaurants with complex processes, which creates a challenge to provide for regulatory oversight.24 Therefore, the Indian food business community must secure the support from policymakers and stakeholders to provide resources to comply with enacted food safety policies, which would bring solutions to strengthen health systems and improve health. This essay aims to address the societal barriers that FBOs are faced with in regards to food safety regulations being imposed on them without governmental support. chapter two: the application of the social ecological model to health behaviorThe Principles of the Social Ecological ModelHealthy behaviors are assumed to be maximized when environments and policies support healthful choices, while individuals are motivated and educated to make those choices.25 For policies to be successful, there must be alignment between the policy and the support from the environment. Educating people to make beneficial choices when environments are not supportive can produce weak and short-term effects.25 Over the years, the application of the social ecological model has been used to provide comprehensive frameworks for understanding the multiple and interacting determinants of health behaviors. Notably the combination of environmental, policy, social, and individual intervention strategies has been attributed to major reductions in tobacco use in the United States since the 1960s.26 This model considers the complex interplay between individual, community, and societal factors, which in this case would allow the governmental bodies to understand the range of factors that put people at risk for food borne illness or protect them from it. The core concept of an ecological model is that behavior has multiple levels of influences, often including intrapersonal (biological, psychological), interpersonal (social, cultural), organizational, community, physical environmental, and policy. 25 Sallis et al. proposed four core principles of ecological models of health behavior which include: 1. There are multiple influences on specific health behaviors, including factors at the intrapersonal, interpersonal, organizational, community, and public policy levels. 2. Influences on behaviors interact across these different levels, meaning these variables work together. 3. Ecological models should be behavior-specific, identifying the most relevant potential influences at each level. 4. Multi-level interventions should be most effective in changing behavior. These four principles collectively highlight the ultimate purpose of the ecological model, which is to develop comprehensive interventions that will systematically target behavioral change through multiple levels of influence. As previously mentioned, behavior change is expected to be maximized when environments, policies, and social norms jointly support healthful choices and when individuals are motivated and educated to make those choices. Understanding Multi-Level Influences on Food Safety As previously mentioned, the social ecological model contributes to understanding the roles that various segments of society can play in making healthy choices more widely desirable. The ecological model considers the interactions between individuals and families, environmental settings and various sectors of influence, as well as the impact of social and cultural norms and values. (adapted from the framework used by the CDC to address the concept of violence.) 27Figure 1. Social Ecological Model LevelsThus, it can be used to develop and implement comprehensive interventions at multiple levels. Figure 1, illustrates how the ecological model is applied in order to understand influences on health behavior and guiding policies and interventions for health behavior change in regards to food safety. The following describes some of the factors and influences found within each element of the model: Individual factors. This level identifies biological and personal factors, such as age, gender, race/ethnicity, education, income, and personal or family history. Prevention strategies at this level are designed to promote attitudes, beliefs and behaviors and may include education and life skills training.25 Street vendors are a good example of how individual factors can influence food safety behaviors since vendors in India oftentimes have lower socio-economic statuses, are uneducated and lack the knowledge for safe food handling.28 Researchers in the past have acknowledged the importance of personal hygiene education as a means to prevent food borne infections originated from street vendors in rural areas in India.29 A study done by Das et al. found that street vendors in rural areas usually prepared and served the food with bare and unwashed hands, which is one of the most probable sources of contamination.29 Another study conducted by Sharmila Rane discovered that those foods prepared by street vendors were prepared either at their homes, stalls or overcrowded areas where high numbers of potential customers would congregate.30 Furthermore, the preparation surfaces of the vendors had remains of foods prepared earlier, which promoted cross contamination.30Consequently, street foods are perceived to be a major public health risk, particularly due to the difficulty in regulating the large numbers of street food vending operations. Their diversity, mobility and temporary nature makes regulatory oversight impossible to fulfill.28 Table 1, illustrates the key findings of a survey where World Health Organization assessed the current situation regarding street-vended food. The WHO suggests that efforts to improve street food vending should focus on educating the food handlers, improving the environmental conditions and providing essential services to the vendors to ensure safety of their commodities.28 Periodic training in safe food handling practice may improve the situation; however, resources are often limited and regulatory services are mostly located in major cities, with little or no monitoring exercised in small towns and rural areas in India.22 Table 1. Key Findings of the WHO Survey of Street Vended Foods74% of countries reported street-vended foods to be a significant part of the urban food supply;Street-vended foods included foods as diverse as meat, fish, fruits, vegetables, grains, cereals, frozen produce and beverages;Types of preparation included foods without any preparation (65%)*, ready-to-eat food (97%) and food cooked on site (82%); Vending facilities varied from mobile carts to fixed stalls and food centers;Infrastructure developments were relatively limited with restricted access to potable water (47%), toilets (15%), refrigeration (43%) and washing and waste disposal facilities;The majority of countries reported contamination of food (from raw food, infected handlers and inadequately cleaned equipment) and time and temperature abuse to be the major factors contributing to foodborne disease; Most countries reported insufficient inspection personnel, insufficient application of the HACCP concept and noted that registration, training and medical examinations were not amongst selected management strategies*Percentage of countries reporting “yes” to questionSource: WHO, 1996 28Interpersonal Relationships.?The second level examines relationships that may increase or reduce a risk of experiencing a negative or positive outcome.25 This usually involves person's closest social circle (peers, partners and family) and how these behaviors can influence the behaviors of others.25 In the case of food safety, interpersonal factors play a key role in habit formation and thus can significantly contribute to better food safety practices. For example, if a mother and daughter occasionally cook meals together and the daughter often witnesses her mother failing to wash her hands before cooking, the daughter may adopt this routine, which would later become a poor habit. Unfortunately, this is a common behavior simply because most consumers believe that food manufacturing facilities and restaurants are obligated to follow food safety laws, while?compliance is generally low in homes.31 Prevention strategies regarding this level should include home food safety messages, particularly designed through media. Community.?The third level explores settings, such as schools, workplaces, churches and neighborhoods, in which social relationships occur. 25 Religious practices play a dominant role in food handling practices in India. In the Indian culture, there is a sheer enjoyment of one’s religious celebrations. Women tend to have primary roles for any religious celebrations at their homes.32 However, the food handling methods adopted by women during religious and social ritual practices are often not adequate to ensure the safety of food.32 Therefore, strategies in this level should be designed to impact context, processes and policies. For example, social marketing campaigns are often used to foster community climates that promote healthy behaviors.25Society/ Institutional/Policy.?The fourth level includes broad societal factors that create a climate in which certain health behaviors are encouraged or inhibited, including social and cultural norms.25 Social norms are shared assumptions of appropriate behavior based on the values of a society and are often reflected in laws or personal expectations.25 With regard to food safety in India, cultural norms include collecting water from a roadside tap or mobile tankers, defecating in open areas, washing hands without soap, keeping foodstuffs uncovered at vending sites, and storing leftovers in warmers or cooking vessels.33 At this level, the responsibility for food safety rests on a variety of sectors such as the government, public health and health care systems, agriculture, and media. Many of these sectors are important in determining the degree to which all individuals and families have access to clean water and opportunities to practice proper food handling in their own communities. Furthermore they can create social policies that help to produce or maintain the status quo, which may include unjustifiable economic and/or social inequalities between social groups. Interventions in this level should focus on using mass media to educate the population of proper food preparation and hygiene, improving environmental conditions of food suppliers, providing essential services to food business operators to ensure safety of their commodities. In essence, individuals are often responsible for their own behaviors; however their societal environment largely determines these behaviors.In summary the basic premise of ecological model helps to understand how people interact with their environments. Providing individuals with motivation and skills to change an undesirable behavior will not be effective if environments and policies make it difficult or impossible to choose healthful behaviors. Therefore, the optimal approach to promoting healthy behaviors must combine all levels to reinforce efforts that are supportive. Furthermore, interventions that address social determinants of health have the greatest potential for public health benefit, however these issues need the support of government and civil society in order to be successful. 34chapter three: a multilevel approach to food safety in the framework of the social ecological modelIn recent years, food safety has become a subject of increasing policy importance internationally. As previously mentioned, the Food Safety and Standards Act (FSS) is an act of Parliament in India, popularly known as the Food Act.4 The regulations of the FSS Act became effective in 2011 with Food Safety and Standards Authority of India as its regulatory body.4 According to the FSS Act, it is mandatory for all food businesses operators, manufacturers, importers, distributers, wholesalers, retailers, hotels, restaurants, eateries, as well as street hawkers/vendors to have an FSSAI registration in order to promote compliance with the FSS Act.?Though the Act continues to evolve, it must be harmonized with political, social, and economic factors in order to promote further growth in the area of food safety.The role of managing food safety should be a shared responsibility between consumers, governmental regulators and private industries. A progressive food safety regulatory system should include the ability to address food safety from farm to table, the use of comparative risk assessment to prioritize public action, an emphasis on prevention policies, open decision-making process involving stakeholders, and evaluation of public health outcomes.35 One of the major difficulties that governmental officials in developing countries face is proposing food safety interventions for food workers without obstructing the operations of their businesses. This tension suggests that emphasis should be on risk prioritization, training, and provision of information, rather than on imposing standards and inspection.35 Likewise, regulators should move towards community-level interventions that support collaborative, multilevel, culturally situated interventions aimed at creating a sustainable impact. In 2013, a panel discussion was conducted by the Clean India Journal, where more than 20 representatives from restaurants, fast food joints and bakeries participated in the conversation.36 These food business operators expressed their need for closer coordination and support from the private stakeholders to ensure compliance, i.e. seminars and workshops.36 In addition, a particularly important part of shared responsibility involves monitoring consumer comments so that modifications can be made to products and processes in order to improve safety as well as the convenience of food.31Translating Social Ecological Model into Recommendations for Food Safety PromotionThe socio-ecological model stimulates multilevel interventions, which seek to create change on various levels. The lack of understanding behavioral frameworks and how they may be translated into policy development is a major limitation of the FSS Act. Despite the widespread success of such interventions in public health, actual multilevel interventions remain scarce. Some studies have argued that the current theoretical framework based on the socio-ecological model is insufficient to guide those seeking to design multilevel interventions.40 Furthermore, they argue that the social ecological model fails to address the gap between theory and translation into practice.40 Therefore, this section proposes complementary interventions that will further enhance food safety promotion in conjunction with the FSS act of India. The core principles of social ecological theory are used to derive practical guidelines for designing these community health promotion programs.Food Regulatory Training Programs Recognition is growing that policymakers can achieve substantially better results by using evidence-based practices to make informed decisions, which would enable governments to select and fund public programs or policies more strategically. A competency-based training program was implemented by Thippaiah et al. in 2012, which served to train Food Safety Officers (FSO) on how to inspect, audit, and conduct food surveillance to ensure food safety and hygiene.21 Thippaiah et. al developed a comprehensive competency-based curriculum with joint efforts of national and international agencies.21 Prior to the development of the training materials, a competency-based training needs assessment was performed to identify the competencies necessary to enforce proper regulatory oversight.21 The professional competencies aimed at food regulators required them to demonstrate a thorough understanding of the FSS Act, effectively undertake the inspection and auditing of food establishments, carry out sampling procedures for food items, and identify the range of hazards that result from food business activities.21 Hence, food regulators received training in microbiology, food surveillance, laboratory systems, and detection of contaminants in food establishment units; identifying emerging food-borne infections; and drawing up a food safety plan for their jurisdiction.21?This training program specifically focused on the urgent need to train and prepare food regulators with high-quality training materials that matched international standards of food regulation.21 Thippaiah et al. stated that the competency-based training program would support the FSS tremendously by expanding food regulatory services to rural areas in the country of India.21 Training is directly related to the promoting skills, knowledge and practices necessary to properly complete a business. In regards to the social ecological model, the food safety-training program is a prevention strategy aimed to target individual and community level matters, since it uses education to impact the knowledge and attitudes of the environment. The training program may also extend to the interpersonal level if these trained officers are promoting food safety practices amongst their personal relationships. Moreover, food safety training would require organizational or governmental support in order to maintain the longevity of training program and to address regulatory inequalities among rural areas in India. Building a Food Safety Culture Through EducationInformation made easily accessible to the public, workers and local communities provides awareness of proper food standards and how they should be integrated into social norms. This strategy provides increased awareness for appropriate food handling practices by extending a food safety culture to the consumers. Studies have established that educating consumers through mass media on proper food hygiene practices will improve the quality of food handling and health in India.38 Studies have also noted that combing education with entertainment is a good route to take when targeting rural audiences.39 Hindi cinema, also known as Bollywood, is one of the largest film producers in the world. Therefore, using locally popular film stars or even featuring religious events would help create a response with rural audiences.39 This strategy will particularly aim to reach rural communities by using conventional and personalized media to change cultural norms regarding food safety, such as word of mouth. Much like India, Belize is a developing country that was faced with increasing infectious diseases transmitted from contaminated food and water.41 In 2005 the Belize Agricultural Health Authority conducted an extensive survey on food safety awareness among Belizean consumers with support from various stakeholders.41 The objective of the survey was to provide information on the current food safety knowledge, attitudes and practices of household consumers in Belize.41 The results of the survey were used to further develop comprehensive and effective food safety public education programs.41 The public’s main source of information on food safety was discovered to be friends and family but other sources included news programs on television and radio followed by educational institutions.41 Hence a collaborative effort between the Belize Agricultural Health Authority (BAHA), the Ministry of Health and other stakeholders led to the Food Safety Awareness Campaign of 2005.41 The Food Safety Awareness Campaign, 2005 sought to promote better food handling practices through coordinated school visits, community forums, public service announcements on radio and TV, talk show discussions, the distribution of educational materials, posters, brochures and refrigerator magnets that Belizeans were encouraged to carry into their homes and schools.41 The campaign included a nationwide essay competition for upper division primary students with "Safe Food Handling: How I can make a difference " as the topic for a 500 word essay to be judged by a panel of food safety regulatory personnel and school educators.41 A monetary prize of $500 (BZD) was offered to the winning student and food items from local producers to be given to the school feeding program of the school that produced the wining student.43 The Food Safety Awareness Campaign is a great example of how a program can seek to promote behavioral changes through community-level approaches such as media and essay competitions. Furthermore, their surveys functioned as a means to identify the public’s main source of information in order to target avenues for the awareness campaign. While Belize and India are different in many ways, India can adapt similar successful campaign strategies as a stepping-stone towards promoting food safety.As previously stated, campaigns are powerful marketing and educational tools that offer insights on issues occurring in the community. Nevertheless, in order for campaigns to be successful they must include a variety of integrated channels. Hence, a successful route for effective learning involves a combination of interactive tactics. For example, Mayer-Mihalski et al. conducted an extensive literature review on adult learning and medical literature in order to understand the materials needed for effective learning that leads to behavior change.42 They formulated six key findings that suggest: Interactive interventions that are more impactful in changing outcomes?include case discussions, practice simulations, roundtable discussions, interactive presentations, sequenced sessions, and enabling materials. 42Behavioral change is a dynamic process resulting from effective design and implementation of education. Elements of an effective learning design are curriculums, tools that enable the learner to use the knowledge in their personal situations. 42Active involvement (“the act of doing”) versus passive participation results in a 90% retention rate two weeks post program. Figure 2 illustrates the Edgar Dale Cone of Learning Model, which compares active and passive learning. 42 In order to achieve behavior change, effective learning methodologies must be incorporated into the program design. These methodologies include blended learning, problem-based learning and simulation. 42 Reinforcement strategies are various interventions that can be used to enhance the learning effectiveness and promote appropriate behavior. Effective reinforcement strategies that influence physician behavior include outreach visits and audits with feedback. 42 Performance metrics must be incorporated into all learning interventions such as pre- and post-tests, follow up surveys and an action plan or commitment to change instrument that allows the learner to reflect on what was learned and how to apply it. 42 Such authors suggest that reinforcement strategies such as "commitment to change" instruments and follow-up reminders must be incorporated into the design of educational programs in order to successfully change the behavior of the learner.45 Adapted from: Edgar Dale, Audio-Visual Methods in Teaching, Holt, Rinehart and Winston42Figure 2. Edgar Dale, Cone of LearningMany studies have looked at geographical features of the viewers in rural states in India. They found acknowledged that rural people differ in many ways such as languages, behavior and cultural values.43 They concluded that advertisements related to youngsters should be shown on the sports channels while products aimed towards women should be shown on Star plus and general channels.43 In addition, the radio advertisements are more appealing to older age persons.43 While media is one of the most effective means of communication, only 57 percent of the total rural households in India have access to mass media of any kind.43 Therefore, using a combination of numerous health promotion strategies may help build a culture of safe food practices in India. Much like the food training and water policy strategies, this prevention would require support from the four aggregate levels (individual, interpersonal, community and societal). Large-scale campaigning designed to promote behavior change practiced in a domestic, institutional (school, hospital) or private sector setting (restaurant, food services) would involve guided technology selection, pilot research funding, and community involvement to ensure this intervention is effective. Therefore, a multi-level support is crucial in the progress of this strategy. recommendationsAs previously mentioned, the Social Ecological Model (SEM) is a framework for understanding the multiple levels of a social system and interactions between individuals and environment within this system. It also serves a model of communication for development, which is important for identifying and incorporating social norms into capacity strengthening and policymaking. Combining the Social Ecological Model with the Food Safety and Standard Act would produce a synergistic effect on food safety in India. Policymakers should use the SEM (1) to understand the complexity and possible avenues for addressing the health problem, (2) to prioritize resources and interventions that address the multiple facets of the problem, (3) and create an enabling environment for sustained behavior and social change. The main objective of this study was to identify multi-level initiatives in the fields of community health, environmental remediation, and food preparation that would support the enacted food safety policy. Past studies have explored behavioral barriers to food safety practices and determined the need for conducting in-service training programs to educate and inform food business operators on food safety.21 Other studies have shown findings that demonstrate that street vended foods constitute an important potential hazard to human health in India.38 Most importantly, they established that regular monitoring of the street foods, while educating consumers through mass media on proper food hygiene practices will improve the quality food handling and health in India.38 However, most of these studies primarily focused on urban regions in India with little attention to rural communities. In view of the regulatory gaps between urban and rural communities, food safety training programs should recruit community health workers as a two-way strategy to provide more regulatory oversight and to promote community health. Aligning these strategies would also create new jobs with the potential to involve rural people in the provision, monitoring and control of basic health services. As previously mentioned, this is a multi-level approach as it involves education and governmental support. Upstream support is needed in order to financially compensate the community health workers and to ensure their accountability to their respective communities. Furthermore, there is a community-level component to the selection of community health workers in India. Selections are made in an open meeting, where important village leaders are involved in the selection.45 The selection process for community health workers reiterates the responsibility these community health workers have on the health status of their communities. Therefore, incorporating community health workers into food safety training programs would enhance this prevention strategy and acknowledge the need for a multi-approach to change cultural norms. In order for India to achieve compliance to food safety polices, complementary community health promotions on personal hygiene must proceed in order to prevent reoccurring foodborne infections from food businesses. Educational campaigns have been noted as powerful marketing and educational tools that offer insights to issues occurring in the community. The Indian government and other stakeholders involved in health promotion should pursue evidence-based practices from other low-income countries and adapt them to the norms within the community. In addition to incorporating successful campaign strategies from other countries, India could integrate previous coordinated campaigns notable for eradicating polio. These campaigns involved collaborations with organizations such as Rotary International,?UNICEF, the World Health Organization, the Indian government, local religious leaders, medical providers, universities, teachers and Bollywood film stars to advertise and administer polio vaccine nationwide.?Furthermore, food safety campaigns must consider the geographical features of the viewers such as language, age and gender. As a result, different broadcasting methods should be used in order to correspond to different genders and age groups.46 Although Hindi is a widely spoken language in India, advertisements spoken primarily in this language may not be communicated to certain audiences. Moreover, policymakers must also acknowledge the unique diversity of India and strategically formulate nationwide polices that can be molded to better fit each state and territory. Therefore, investing in a multifaceted approach that addresses barriers to health promotion can improve the quality of information delivered to the population and help eliminate disparities in health communication.Lastly, the Prime Minster and Parliament must work cohesively towards enacting future legislations. In regards to the constitution, law-making powers were explicitly given to the Parliament and should not be manipulated by the Cabinet ministers.15 Consequently, the Cabinet Ministers should be given stringent guidelines towards developing a successful policy before these policies are passed by the Parliament. Although success of a policy is often trial and error, the Council of Ministers responsible for conceptualizing these policies must stretch their thoughts in order to foresee challenges that may arise from these policies. Policymakers should also use preliminary tools such as a SWOT analysis to assess the social ecological landscape prior to developing a policy. In addition, policies affecting the individuals under jurisdiction (FBOs) should include their insights into the policymaking process, which will not only ensure the longevity of the FSS act, but it also gives the community motivation to adhere to them. Although access to safe water is outside the scope of this essay, it is important to acknowledge its relevancy regarding food safety. Poor water quality poses an additional hazard to food safety in developing countries. Most food handlers draw water from city water supplies or wells with the assumption is that these are safe water sources. Therefore, it is important for the government and stakeholders to team up and address the issues surrounding access to clean water as it relates to public health practice. This includes actions to update drinking water standards, protect drinking water sources, modernize the tools available to communities to meet their clean water requirements, and installing water well services in rural communities.??Overall, the novelty of this essay draws attention to the multilevel factors that could influence a society’s behavior. It is expected that findings from this paper may provide some recommendations that may be useful for implementing interventions that will complement the enacted Food Safety and Standards act and reduce incidences of food-borne illness in India. APPENDIX: THE FEDERAL STRUCTURE OF THE REPUBLIC OF INDIAbibliographyCenter of Disease and Control. (2011, August). Defeating diarrheal disease: Tracking the source of foodborne infections. Retrieved from ., Koopmans,?M., Verhoef,?L., Duizer,?E., Aidara-Kane,?A., Sprong,?H., Opsteegh,?M. (2010, May 30). Food-borne diseases — The challenges of 20years ago still persist while new ones continue to emerge. Retrieved from ., Kumar,?R., & Polasa,?K. (1987, June). Foodborne diseases in India-a review. Retrieved from Of Law And Justice. (2006, August 24). Food Safety and Standards Act, 2006. Retrieved from . (2015, December 7). The World Factbook. Retrieved from . (2013). Addressing language barriers to healthcare in India. Retrieved from , A. The Epidemiologic Transition: A Theory of the Epidemiology of Population Change. (2005) Retrieved on October 4, 2015 from ., Jane,?S., Sharma,?A., Kumar,?A., & Narain,?J. (2013, July). Emerging & re-emerging infections in India: An overview. Retrieved from Health Organization. Nutrition: the double burden of disease. (2014). Retrieved on October 4, 2015 from SJ, Sathar ZA. Women’s autonomy in India and Pakistan: the influence of region and religion. Retrieved from ., Selvaraj,?S., & Subramanian,?S. (2011, January 10). Health care and equity in India. Retrieved from ., Mitra,?P., Puri,?A., & Vaidya,?M. (2012, December). India Healthcare: Inspiring possibilities, challenging journey. Retrieved from (1).pdfWorld Bank. (2015). Poverty headcount ratio at $1.90 a day (2011 PPP) (% of population). Retrieved from . (1990). Introduction: Continuities and Discontinuities between Pre- and Post- Independence India. In?The politics of India since independence?(2nd?ed., p.?5). Retrieved from of India Ministry of Law and Justice. (2007, December 1). The Constitution of India. Retrieved from of India. (1935, August 2). Government of India Act 1935. Retrieved from of India. (2015, November 16). Ministry of Health & Family Welfare. Retrieved from of Health and Family Welfare. (2004, January 10). The Prevention of Food Adulteration Act and Rules. Retrieved from of Health and Family Welfare. (2012, December 9). Prevention of Food Adulteration Programme. Retrieved from ., Sharma,?S., Singh,?U., Triphathy,?A., Parida,?M., & Prasad,?A. (2006). Food Safety and Standards Authority of India (FSSAI). Retrieved from ., Allagh,?K., & Murthy,?G. (2014, July 19). Challenges in developing competency-based training curriculum for food safety regulators in India. Retrieved from and Agriculture Organization. (2005). National Food and Safety Systems In Africa-A Situation Analysis. Retrieved from Initiative. (2015). Food safety in India – Regulatory framework and challenges. Retrieved from . (2015, August 18). Food Safety Laws & Challenges in India. Retrieved from . (2015, February). Primary Health Care and Public Health: Foundations of Universal Health Systems. Retrieved from of Medicine. (2001). Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Retrieved from for Disease Control and Prevention. (2015, March 25). The Social-Ecological Model: A Framework for Violence Prevention. Retrieved from Health Organization. (1996). Essential Safety Requirements For Street-Vended Foods. Retrieved from ., Rath,?C., & Mohaparta,?U. (2012, October). Bacteriology of a most popular street food (Panipuri) and inhibitory effect of essential oils on bacterial growth. Retrieved from . (2011, January 5). Street Vended Food in Developing World: Hazard Analyses. Retrieved from ., Porticella,?N., Jiang,?L., & Gravani,?R. (2011, February). Predicting Intentions to Adopt Safe Home Food Handling Practices. Applying the Theory of Planned Behavior. Retrieved from ., & Ramesh Kumar,?S. (2014, June). Food Safety Knowledge and Practices of Consumers in Tamil Nadu. Retrieved from ., Hazarika,?N., Hazarika,?D., & Mahanta,?J. (1999, September). Prevalence of communicable disease among restaurant workers along a highway in Assam, India. Retrieved from ., Bell,?R., Houweling,?T., & Marmot,?M. (2009). Closing The Gap In A Generation: health equity through action on the social determinants of health. Retrieved from ., & Hirschhorn,?N. (2000, May). Food Safety Issues in the Developing World. Retrieved from India Journal. (2014, March 18). Challenges in implementation of FSSAI Regulations. Retrieved from . (2013, July). India's History-Republic of India. Retrieved from ., & Mazumdar,?J. (2014). Assessment of bacteriological quality of ready to eat food vended in streets of Silchar city, Assam, India. Retrieved from ., Moharana,?T., & Beura,?D. (2010, May 27). Communication Strategy for Rural Markets: A Study on India. Retrieved from ., & Kawachi,?I. (2016, February). Translating the Socio-Ecological Perspective Into Multilevel Interventions: Gaps Between Theory and Practice. Retrieved from Agricultural Health Authority. (2005, December). FAO/WHO Regional Conference on Food Safety for the Americas and the Caribbean. Retrieved from ., & DeLuca,?M. (2009, May). Effective Education Leading to Behavior Change. Retrieved from ., & Dev,?K. (2013, September). Effective Media for Rural Communication: A Study of Panipat Area. Retrieved from . (2013, August 27). Functions of Council of Ministers in India. Retrieved from Health Organization. (2004). What Works for Children in South Asia Community Health Workers. Retrieved from ................
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