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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
BIBLIOGRAPHY
1. Center of Disease and Control. (2011, August). Defeating diarrheal disease: Tracking the source of foodborne infections. Retrieved from http://www.cdc.gov/ncezid/dfwed/pdfs/factsheet-india.pdf
2. Newell, D., 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 http://www.sciencedirect.com/science/article/pii/S0168160510000383
3. Sudershan, V., Kumar, R., & Polasa, K. (1987, June). Foodborne diseases in India-a review. Retrieved from http://www.emeraldinsight.com/doi/abs/10.1108/00070701211229954
4. Ministry Of Law And Justice. (2006, August 24). Food Safety and Standards Act, 2006. Retrieved from http://www.fssai.gov.in/Portals/0/Pdf/FOOD-ACT.pdf
5. CIA. (2015, December 7). The World Factbook. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/geos/in.html
6. Narayan, L. (2013). Addressing language barriers to healthcare in India. Retrieved from http://nmji.in/archives/Volume-26/Issue-4/SFM-II.pdf
7. Omran, A. The Epidemiologic Transition: A Theory of the Epidemiology of Population Change. (2005) Retrieved on October 4, 2015 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690264/
8. Dikid, T., Jane, S., Sharma, A., Kumar, A., & Narain, J. (2013, July). Emerging & re-emerging infections in India: An overview. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3767269/
9. World Health Organization. Nutrition: the double burden of disease. (2014). Retrieved on October 4, 2015 from http://www.who.int/nutrition/topics/2_background/en/index1.html
10. Jejeebhoy SJ, Sathar ZA. Women’s autonomy in India and Pakistan: the influence of region and religion. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1728-4457.2001.00687.x/abstract
11. Balarajan, Y., Selvaraj, S., & Subramanian, S. (2011, January 10). Health care and equity in India. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093249/
12. Gudwani, A., Mitra, P., Puri, A., & Vaidya, M. (2012, December). India Healthcare: Inspiring possibilities, challenging journey. Retrieved from http://file:///Users/DrNwoka/Downloads/India_healthcare_Inspiring_possibilities_and_challenging_journey_Executive_Summary%20(1).pdf
13. World Bank. (2015). Poverty headcount ratio at $1.90 a day (2011 PPP) (% of population). Retrieved from http://data.worldbank.org/indicator/SI.POV.DDAY
38
14. Brass, P. R. (1990). Introduction: Continuities and Discontinuities between Pre- and Post- Independence India. In The politics of India since independence (2nd ed., p. 5). Retrieved from https://books.google.com/books?hl=en&lr=&id=dtKe6XV8z7wC&oi=fnd&pg=PR10&dq=history+of+politics+in+india&ots=DEZXdCHdwO&sig=YaZQmQqCB3o2CuTRqFJYowxmf5g#v=onepage&q&f=false
15. Government of India Ministry of Law and Justice. (2007, December 1). The Constitution of India. Retrieved from http://lawmin.nic.in/coi/coiason29july08.pdf
16. Government of India. (1935, August 2). Government of India Act 1935. Retrieved from http://www.legislation.gov.uk/ukpga/Geo5and1Edw8/26/2/enacted
17. Government of India. (2015, November 16). Ministry of Health & Family Welfare. Retrieved from http://www.mohfw.nic.in/
18. Ministry of Health and Family Welfare. (2004, January 10). The Prevention of Food Adulteration Act and Rules. Retrieved from http://dbtbiosafety.nic.in/act/PFA%20Acts%20and%20Rules.pdf
19. Ministry of Health and Family Welfare. (2012, December 9). Prevention of Food Adulteration Programme. Retrieved from http://www.archive.india.gov.in/sectors/health_family/food_prevention.php
20. Bahuguna, S., Sharma, S., Singh, U., Triphathy, A., Parida, M., & Prasad, A. (2006). Food Safety and Standards Authority of India (FSSAI). Retrieved from http://www.fssai.gov.in/AboutFSSAI/introduction.aspx
21. Thippaiah, A., Allagh, K., & Murthy, G. (2014, July 19). Challenges in developing competency-based training curriculum for food safety regulators in India. Retrieved from http://www.ijcm.org.in/article.asp?issn=0970-0218;year=2014;volume=39;issue=3;spage=147;epage=155;aulast=Thippaiah
22. Food and Agriculture Organization. (2005). National Food and Safety Systems In Africa-A Situation Analysis. Retrieved from http://www.fao.org/docrep/meeting/010/a0215e/A0215E24.htm#ref24.1
23. Swaniti Initiative. (2015). Food safety in India – Regulatory framework and challenges. Retrieved from http://www.swaniti.com/wp-content/uploads/2015/06/Food-safety-in-India-1.pdf
24. Balaji B. (2015, August 18). Food Safety Laws & Challenges in India. Retrieved from https://www.linkedin.com/pulse/food-safety-laws-challenges-india-bharati-balaji?forceNoSplash=true
25. White, F. (2015, February). Primary Health Care and Public Health: Foundations of Universal Health Systems. Retrieved from https://www.karger.com/Article/FullText/370197
26. Institute of Medicine. (2001). Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20669491
27. Center for Disease Control and Prevention. (2015, March 25). The Social-Ecological Model: A Framework for Violence Prevention. Retrieved from http://www.cdc.gov/violenceprevention/overview/social-ecologicalmodel.html
28. World Health Organization. (1996). Essential Safety Requirements For Street-Vended Foods. Retrieved from http://apps.who.int/iris/bitstream/10665/63265/1/WHO_FNU_FOS_96.7.pdf
29. Das, M., 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 http://www.ncbi.nlm.nih.gov/pubmed/24082267
39
30. Rane, S. (2011, January 5). Street Vended Food in Developing World: Hazard Analyses. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3209856/
31. Shapiro, A., 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 http://www.ncbi.nlm.nih.gov/pubmed/21115082
32. Gnanasumathi, S., & Ramesh Kumar, S. (2014, June). Food Safety Knowledge and Practices of Consumers in Tamil Nadu. Retrieved from http://shodhganga.inflibnet.ac.in:8080/jspui/bitstream/10603/38426/19/19_publication.pdf
33. Biswas, D., Hazarika, N., Hazarika, D., & Mahanta, J. (1999, September). Prevalence of communicable disease among restaurant workers along a highway in Assam, India. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10774665
34. Friel, S., 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 http://www.ncbi.nlm.nih.gov/pubmed/18994664
35. Unnevehr, L., & Hirschhorn, N. (2000, May). Food Safety Issues in the Developing World. Retrieved from http://www-wds.worldbank.org/servlet/WDSContentServer/WDSP/IB/2000/08/14/000094946_00072805374210/Rendered/PDF/multi_page.pdf
36. Clean India Journal. (2014, March 18). Challenges in implementation of FSSAI Regulations. Retrieved from http://www.cleanindiajournal.com/challenges-in-implementation-of-fssai-regulations/
37. Thapar, R. (2013, July). India's History-Republic of India. Retrieved from http://www.britannica.com/place/India
38. Sharma, I., & Mazumdar, J. (2014). Assessment of bacteriological quality of ready to eat food vended in streets of Silchar city, Assam, India. Retrieved from http://www.ijmm.org/article.asp?issn=0255-0857;year=2014;volume=32;issue=2;spage=169;epage=171;aulast=Sharma
39. Mohapatra, N., Moharana, T., & Beura, D. (2010, May 27). Communication Strategy for Rural Markets: A Study on India. Retrieved from http://www.indianmba.com/Faculty_Column/FC1164/fc1164.html
40. Schölmerich, V. L., & Kawachi, I. (2016, February). Translating the Socio-Ecological Perspective Into Multilevel Interventions: Gaps Between Theory and Practice. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/26747715
41. Belize Agricultural Health Authority. (2005, December). FAO/WHO Regional Conference on Food Safety for the Americas and the Caribbean. Retrieved from http://www.fao.org/3/a-af211e.pdf
42. Mayer-Mihalski, N., & DeLuca, M. (2009, May). Effective Education Leading to Behavior Change. Retrieved from http://www.paragonrx.com/experience/white-papers/effective-education-leading-to-behavior-change/
43. Kaushik, R., & Dev, K. (2013, September). Effective Media for Rural Communication: A Study of Panipat Area. Retrieved from http://www.ijcem.org/papers092013/ijcem_092013_02.pdf
44. Jaiswal, V. (2013, August 27). Functions of Council of Ministers in India. Retrieved from http://www.importantindia.com/2066/functions-of-council-of-ministers-in-india/
45. World Health Organization. (2004). What Works for Children in South Asia Community Health Workers. Retrieved from http://www.unicef.org/rosa/community.pdf
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