TRANSLATING THE SOCIAL ECOLOGICAL MODEL INTO

RECOMMENDATIONS FOR FOOD SAFETY PROMOTION IN INDIA

by

Adaobi U. Nwoka

BS, Howard University, 2012

Submitted to the Graduate Faculty of

Health Policy and Management

Graduate School of Public Health in partial fulfillment

of the requirements for the degree of

Master of Public Health

University of Pittsburgh

2016

ii

UNIVERSITY OF PITTSBURGH

GRADUATE SCHOOL OF PUBLIC HEALTH

This essay is submitted

by

Adaobi Nwoka

on

April 10th, 2016

and approved by

Margaret A. Potter, JD, MS ______________________________________ProfessorHealth Policy and ManagementAssociate Dean for Public Health PracticeGraduate School of Public HealthUniversity of Pittsburgh

Joanne Russell, MPPM ______________________________________Assistant ProfessorBehavioral and Community Health ScienceDirector, Center of Global HealthGraduate School of Public HealthUniversity of Pittsburgh

iii

Copyright © by Adaobi Nwoka

2016

ABSTRACT

iv

Foodborne 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.

v

Margaret A. Potter, JD, MS

TRANSLATING THE SOCIAL ECOLOGICAL MODEL INTO

RECOMMENDATIONS FOR FOOD SAFETY PROMOTION IN INDIA

Adaobi Nwoka, MPH

University of Pittsburgh, 2016

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 Safety

vi

TABLE OF CONTENTS

LIST OF ACRONYMS................................................................................................................X

PREFACE....................................................................................................................................XI

1.0 INTRODUCTION.........................................................................................................1

1.1 PUBLIC HEALTH RELEVANCE.....................................................................3

2.0 CHAPTER ONE: THE DEMOGRAPHIC OVERVIEW OF INDIA.....................4

2.1 THE DEMOGRAPHICAL CONTEXT OF INDIA..........................................4

2.2 HISTORICAL FRAMEWORK OF INDIA......................................................6

2.3 POLITICS IN INDIA AFTER INDEPENDENCE...........................................7

2.4 ROLE OF THE GOVERNMENT IN PUBLIC HEALTH...............................9

2.5 THE FOOD SAFETY AND STANDARDS ACT OF INDIA........................11

3.0 CHAPTER TWO: THE APPLICATION OF THE SOCIAL ECOLOGICAL

MODEL TO HEALTH BEHAVIOR.........................................................................................14

3.1 THE PRINCIPLES OF THE SOCIAL ECOLOGICAL MODEL...............14

3.2 UNDERSTANDING MULTI-LEVEL INFLUENCES ON FOOD SAFETY. .

..................................................................................................................................

16

4.0 CHAPTER THREE: A MULTILEVEL APPROACH TO FOOD SAFETY IN

THE FRAMEWORK OF THE SOCIAL ECOLOGICAL MODEL.....................................21

vii

4.1 TRANSLATING SOCIAL ECOLOGICAL MODEL INTO

RECOMMENDATIONS FOR FOOD SAFETY PROMOTION...................................23

5.0 RECOMMENDATIONS............................................................................................30

APPENDIX: THE FEDERAL STRUCTURE OF THE REPUBLIC OF INDIA.................34

BIBLIOGRAPHY........................................................................................................................35

viii

LIST OF TABLES

Table 1. Key Findings of the WHO Survey of Street Vended Foods............................................18

ix

LIST OF FIGURES

Figure 1. Social Ecological Model Levels.....................................................................................16

Figure 2. Edgar Dale, Cone of Learning........................................................................................28

x

LIST OF ACRONYMS

xi

PREFACE

xii

Acronym Definition

AYUSH Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy

BAHA Belize Agricultural Health Authority

FBO Food business Operators

FSS Food Safety and Standards

FSSAI Food Safety and Standards Authority of India

FSO Food Safety Officers

GWP Global Water Partnership

HACCP Hazard Analysis Critical Control Point

HIV Human Immunodeficiency Virus

IUWM Integrated Urban Water Management

LMIC Low and middle income countries

MOHFW Ministry of Health and Family Welfare

PFA Prevention and Food Adulteration

SEM Social Ecological Model

WAPCOS Water and Power Consultancy Services

WHO World Health Organization

This 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.

xiii

1.0 INTRODUCTION

Over 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.

1

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.

2

1.1 PUBLIC HEALTH RELEVANCE

Food 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.

3

2.0 CHAPTER ONE: THE DEMOGRAPHIC OVERVIEW OF INDIA

2.1 THE DEMOGRAPHICAL CONTEXT OF INDIA

India 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

4

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.11

In 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. 13

5

2.2 HISTORICAL FRAMEWORK OF INDIA

Until 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.37

The 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.37

6

7

2.3 POLITICS 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

8

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.44

The 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.15

9

10

2.4 ROLE OF THE GOVERNMENT IN PUBLIC HEALTH

The 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). 17

The 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,

11

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.

12

2.5 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.

13

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

14

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.23

In 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.

15

3.0 CHAPTER TWO: THE APPLICATION OF THE SOCIAL ECOLOGICAL

MODEL TO HEALTH BEHAVIOR

3.1 THE PRINCIPLES OF THE SOCIAL ECOLOGICAL MODEL

Healthy 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,

16

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.

17

3.2 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.) 27

Figure 1. Social Ecological Model Levels

18

Thus, 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.30

Consequently, 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

19

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 Foods

74% 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 question

Source: WHO, 1996 28

20

Interpersonal 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.25

Society/ 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

21

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. 34

22

23

4.0 CHAPTER THREE: A MULTILEVEL APPROACH TO FOOD SAFETY

IN THE FRAMEWORK OF THE SOCIAL ECOLOGICAL MODEL

In 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

24

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.31

25

4.1 TRANSLATING SOCIAL ECOLOGICAL MODEL INTO

RECOMMENDATIONS FOR FOOD SAFETY PROMOTION

The 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

26

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 Education

Information made easily accessible to the public, workers and local communities

provides awareness of proper food standards and how they should be integrated into social

27

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,

28

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:

1. Interactive interventions that are more impactful in changing outcomes include case

discussions, practice simulations, roundtable discussions, interactive presentations,

sequenced sessions, and enabling materials. 42

29

2. Behavioral 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. 42

3. Active 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

4. 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

5. 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

6. 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

30

Adapted from: Edgar Dale, Audio-Visual Methods in Teaching, Holt, Rinehart and Winston42

Figure 2. Edgar Dale, Cone of Learning

Many 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

31

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.

32

5.0 RECOMMENDATIONS

As 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

33

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,

34

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

35

(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.

36

APPENDIX: THE FEDERAL STRUCTURE OF THE REPUBLIC OF INDIA

37

PRESIDENT

Legislative

Parliment

Lok Sabha Rajya Sabha

Executive

Prime Minister and

Cabinet

Ministries Statutory Boards and Similar

Bodies

Judiciary

Supreme Court

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