Hygiene in restaurants and among street food vendors in Bangladesh 1 Md. Fosiul Alam Nizame Assistant Scientist WASH Research Group, icddr,b Water and Health Conference Chapel Hill, North Carolina October 29, 2015

Background Food and waterborne diseases are major causes of illness and death in less developed countries 1 Poor personal and environmental hygiene contribute significantly to food contamination 2 Outbreaks of food borne disease have been linked to poor hygiene in restaurants and eating food from street vendors 3,4 Availability of water and soap at handwashing place can have an impact on hygiene practices 5 Ref. 1. WHO 2002, 2. Mathee, A. et al 1996, 3. Todd et al 2008, 4. Vollaard et al 2004, 5. Luby et al

Bangladesh Ministry of Health and Family Welfare (MOHFW) have major responsibility to ensure safe food by doing inspection of food processing and selling 6 Food hygiene indicators such as practices, facilities and perceptions are not available for street food vendors and restaurants Nationally representative indicator data can be used to advocate for intervention programs and used to measure progress of the planned National Hygiene Promotion Strategy 7 Ref. 6. Laws and regulation of foods and food additives, Bangladesh country report. 7. National Hygiene promotion Strategy for Water Supply and Sanitation Sector in Bangladesh

Objectives To obtain nationally representative data on hygiene practices, facilities, barriers and perceptions among street food vendors and restaurants To use data for advocacy, hygiene intervention development and planning 4

● ● = Rural Clusters ● ● = Urban Clusters Study area and period Data collection period: January to October

Study population Restaurants: - Manager - Cook - Service staff Street food vendors Sell food in a street/public location without having a permanently built structure but a temporary static structure or mobile stall 6 A low-middle class restaurant A street food vendor

50 Rural Clusters 100 clusters (probability proportion to size of population) Survey: 3 restaurants, Total 300 Survey: 6 street food vendors, Total Urban Clusters Sampling 7

Data collection methods Structured observation (90 Minutes) [300 cooks service staff vendors] 8 Spot check [300 restaurants vendors] Structured interview [300 cooks service staff vendors] In-depth interview [service staff/cooks and street food vendors (N=64 )] Hygiene facilities and practices. Perceptions regarding hand/food hygiene and related barriers, and their thoughts on customer’s satisfaction

9 Kept food inside kitchenStored water inside restaurantCutting vegetables inside kitchenA street food vendor preparing/serving food

IndicatorsRestaurant Street food vendor Male manager/Owner99%97% Male cook81%- Male service staff98%- Median age of manager 40 Years35 Years No formal education: manager13% 52% Median hours open each day16 8 Characteristics of businesses 10

Handwashing agents available 11 In restaurants food preparation area In handwashing location for customers Spot check

Service staff Restaurant handwashing with soap reported versus observed 12 % Total HW opportunities observed =2656

Restaurant handwashing with soap reported versus observed 13 % Total HW opportunities observed =716 Cook

% Street food vendor handwashing with soap reported versus observed 14 Total HW opportunities observed =8491

Toilet within premises (restaurants) 15

How do street food vendors access toilet facilities? 16 %

Almost all (99%) of the water sources used by restaurants and food vendors were improved. Drinking water treatment and storage 17

Observation of cleaning utensils 18

Food items kept in a covered and clean pot/container for sale: Restaurants: 3 – 25% of foods were kept covered Food vendors: 5 – 42 % of foods were kept covered Food hygiene (spot check) 19

Respondents’ thoughts on customer satisfaction Factors RestaurantFood vendors N=32 (%) N=32 (%) Tasty food6378 Clean utensils4428 Well-mannered behavior3425 Different variety of food4416 Fresh food (Not stale/preserved food)1916 Cheap food283 Covering food with lid Nobody can make foods as tasty as me. That’s why customers don’t buy foods from other vendors if I am present over there” (A mixed puffed rice seller of a rural area)

Most (80%) respondents reported that during food preparation and serving they do not touch dirty things 14% of respondents equated contact with water to handwashing All respondents believed that tube well water is germ free 21 Perception of contamination and handwashing

Barriers to washing hands with soap Carrying soap and water is not possible (vendors) High volume of customers and fast-paced work Soap is costly Lack of awareness and negligence 22 “I always move from one place to another, so carrying water and soap is a hassle for me, therefore I can’t wash hands with soap while I am selling food on the street” (A street food vendor from a rural area) A street food vendor

23 “We can’t wash hands with soap as we have to serve customers so frequently. If we can’t serve quickly then customers get angry. Customers should have patience on this issue” (A restaurant service staff from an urban area) “ We people are poor. Sometimes soap is available in my restaurant and sometimes not. When there is no soap we wash our hands with water only”(A restaurant manager from an urban area)

Conclusion Restaurant staff and street food vendors in Bangladesh do not usually wash their hands with soap during food handling - Limited facilities contributes to a lack of hand and food hygiene - Impractical for street food vendors to carry and store water - Cost of soap is also a barrier Equated handwashing with hands contacting water Respondents perceived that customers are satisfied if they get tasty food 24

Considerations for an intervention Messages should stress that only hand dipping into water is not adequate to remove contaminants Encourage using inexpensive alternative; soapy water 25 A handwashing station with a soapy water bottle Promote the marketing of hygienic food to attract and retain happy customers Involve customers in the interventions, they can demand hygienic food

Next step and future research Share study findings with government inspectors Explore what motivates customers to purchase from or avoid restaurants and food vendors - how important hygiene is? what hygiene measures they would like to see? Develop and pilot: - an intervention that has a customer and business profit focus to improve hygiene practices by restaurants and food vendors - a hand sanitizer acceptability and feasibility intervention to improve hygiene practices by street food vendors 26

Icddr,b team: Leanne Unicomb Amal K Halder Mahbub-Ul Alam Fosiul A Nizame Statistician Field Team - Senior/Research Officers - Field Research Assistants Technical partners: PSU, Government of Bangladesh WaterAid Buffalo University: Pavani K Ram Wit Wichaidit Stanford University: Stephen P Luby Lily Horng Collaborators 27 Study participants Diana DiazGranados Study team Acknowledgements

icddr,b thanks its Core Donors 28