The role of educational intervention in changing knowledge and attitudes of rural homemakers in relation to food safety and hygiene: A case study: Iran (2016)


Background: Food hygiene is one of the fundamental and essential issues in environmental health that should be followed to prevent food-borne illnesses. Objective: This cross-sectional study aimed at determining the role of educational intervention in changing knowledge and attitudes of rural homemakers in the city of Bisotun toward food hygiene. Materials and Methods: The first step to conduct the study was designing a survey questionnaire. We selected rural homemakers of the villages of Bisotun as target population for the study and a used random sampling for selecting a hundred of them. All achieved data were analyzed by SPSS and evaluated using independent t-test and ANOVA at a significance level of α = 0.05. Results: There was a significant difference (P < 0.05) in knowledge of the studied rural homemakers depending on their marital status, use of media, education, and age. The results showed that the educational intervention elevated their knowledge. Besides, there was also a significant difference (P < 0.05) based on different demographic variables in attitudes of the studied rural homemakers toward food hygiene. Conclusion: From the results, it can be concluded that the regional health workers failed to follow guidelines for improving the situation because of the multiplicity and diversity of their duties. It seems, therefore, that there is a need to use periodical educations (every 6 months) intending to teach important subjects such as food hygiene to rural homemakers and even health workers by experienced and highly educated food hygiene professionals, considering parameters including gender, age, and education of the individuals.

Keywords: Attitude, Bisotun, educational intervention, food hygiene, knowledge, rural homemakers

How to cite this article:
Safari Y, Sharafie K, Karimaei M, Asadi F, Ghayebzadeh M, Motlagh ZJ, Mirzaei N, Sharafi H. The role of educational intervention in changing knowledge and attitudes of rural homemakers in relation to food safety and hygiene: A case study: Iran (2016). Ann Trop Med Public Health 2017;10:1024-31


How to cite this URL:
Safari Y, Sharafie K, Karimaei M, Asadi F, Ghayebzadeh M, Motlagh ZJ, Mirzaei N, Sharafi H. The role of educational intervention in changing knowledge and attitudes of rural homemakers in relation to food safety and hygiene: A case study: Iran (2016). Ann Trop Med Public Health [serial online] 2017 [cited 2021 Apr 14];10:1024-31. Available from:



Food safety and hygiene are necessary to ensure the environment maintenance and prevention of disease outbreaks among populations.[1] The statistics show that many people in the world suffer from food-borne illnesses and the number of them is growing.[2] It might be caused by public health problems increases in both developed and developing countries, which may hit the health and economy of the latter.[3] The results of several studies suggest that inappropriate consumption behaviors such as consumption of raw or undercooked food and unhygienic practices in food production may affect the transmission of food-borne illnesses. Certain studies, conducted in Europe and North America, have shown that a significant proportion of food-borne illnesses are resulted from improper food handling practices, witnessed among food handlers with poor personal hygiene. They may not wash their hands after using the toilet and transfer, for instance, bacteria from raw meat to green salads, which leads to cross-contamination.[4],[5],[6] Investigations have revealed that in 70% of cases food poisoning were reported as a result of improper food storage time and temperatures and in 30% of them as a result of cross contamination. As a matter of fact unhygienic practices of food storage, handling and preparation could contribute to transmission of pathogens including Campylobacter,  Salmonella More Details, Hepatitis A virus and viruses causing diarrhea.[6] That in the United States and Europe, the number of diseases transmitted through food is reported 45% and 22%, respectively.[7]

Food-borne illnesses are usually associated with symptoms such as vomiting, diarrhea, headache, fever, fatigue, abdominal cramping, and blood and pus in the stool.[8] Food safety and hygiene are not only indissolubly linked to important issues such as obesity, but noncompliance of their requirements and subsequent diseases could impose costs on the individuals, food industry, public health system, and general economy of the country.[9] Researchers estimate that food-borne illnesses cause approximately 76 million diseases, 325,000 hospitalizations, and 5,000 deaths in the USA each year.[10],[11],[12],[13] Since food preparation and storage are mainly considered homemakers’ task, a high-level of knowledge and proper attitudes toward food hygiene are indispensable for them, especially in rural communities that compared to their urban analogs are often less provided with educational and recreational facilities. Adult education in Iran’s villages is not well developed, and rural homemakers have more educational needs. Furthermore, even the health workers may not succeed in teaching all required subjects to rural dwellers (especially homemakers) due to the multiplicity of their tasks. Based on the earlier studies, well-organized education and training pathways and compliance guidelines and recommendations can play a leading role in changing knowledge and attitudes of people including women,[14],[15],[16],[17],[18] but it may not be effective for all parts of the target population. The foregoing surveys of knowledge and attitudes of people toward food hygiene, undertaken in Iran, covered only the primary assessment of the target population without considering the role of education.


This study, therefore, is focused on the role of educational intervention in changing knowledge and attitudes of rural homemakers based on their age, gender, possible education by media or health workers, and other parameters. We selected rural homemakers of the village Bisotun near the city of Kermanshah as target population for the study in 2016.

Materials and Methods

As the first step to conduct this experimental study, we designed a survey questionnaire. The validity of the questionnaire was estimated by content assessment. For this purpose, we distributed the questionnaires to 6 members of the faculty of health sciences and 6 health workers at the rural health clinic to be evaluated in terms of content and method accordance with the defined goals. Pearson correlation coefficient (r) for the questions of knowledge and attitudes was 0.8 and 0.7, respectively. The questionnaire encompassed three sections. The first section focused on the demographic data and the second section with 33 questions concerned the respondent’s knowledge and to each question was assigned 1 point value. The third section also consisted of 33 questions aimed to investigate respondent’s attitudes and to each of them was assigned 3 points value. It should be noted that for better and easier access to interviewees we randomly selected two countryside villages of the city Bisotun by cluster sampling and 50 people from each of the two villages. Twenty of these 50 selected people had primary and secondary school certification, 15 of them high school certificate and the rest of them an academic degree. We invited the interviewees to complete the questionnaires at the pre- and post-test stages of the experiment. Thus, after the pretest stage, we collected all the data, analyzed them and then, based on the results, developed the educational content and program. One month after launching the educational program, we asked the participants to fill in the questionnaire at the posttest stage of the experiment. After comparing the results of pre- and post-tests, we categorized the participants, according to the point values for their knowledge and attitudes, into a four-level hierarchy: poor, medium, good, and very good, as shown in [Table 1] and [Table 2]. The results of the pre- and post-tests were transferred into SPSS version 16, and the outputs were estimated using paired t-test at a significance level of 0.05 to investigate the role of education in changing knowledge and attitudes of the respondents and were interpreted by descriptive statistics. Rating questionnaire responses by Likert scale resulted in 5 components for knowledge and 6 components for attitudes shown in [Table 1] and [Table 2].

Table 1: The results scoring of the study in terms of knowledge of the evaluated items based on the Likert scale

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Table 2: The results scoring of the study in terms of attitude of the evaluated items based on the Likert scale

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The target population in this study consisted of 100 rural homemakers, 39 of which single and 61 married. The average scores for knowledge in single and married women before the education were 38.23 and 28.20, respectively, that emphasized the higher level of knowledge in the single women compared to the married. The average scores for knowledge in single and married women after the education were raised to 21.25 and 24.11, respectively. The corresponding statistical analyses divulged that the knowledge level in married women compared to the single women before and after the education was different (P = 0.041), but this undertook reduction after the education (P = 0.21). Eighty-eight rural homemakers were provided with education by health workers while 12 of them lacked such an experience. The average score difference for knowledge in the educated rural homemakers (21.01) compared to the uneducated ones by health workers (17.83) was dramatic (P = 0.02), which reached reduction after the educational intervention (0.86). 96 rural women in this study used media such as TV and newspaper to develop their knowledge of food hygiene. Their average score for knowledge was 21. This score for 4 other women in the target population, who did not use media for the above-mentioned purpose at all, was 18.47. According to the results of the statistical analyses, there was a significant difference between the average scores of these two groups of women (P = 0.047), which achieved reduction after the education (P = 0.47). The use of media in the target population for educational purposes relating to food hygiene was subcategorized into poor (including 15 women), average (including 62), and high (including 19 women) levels. There was a significant difference between the average scores for knowledge at poor (19.1) and high (23.47) was 0.039, which disappeared after the education (P = 0.127). The target population was divided into 4 groups in terms of age: A = under 20 (including 14 women), B = between 21 and 40 (including 70 women), C = between 41–60 (including 14 women), and D = above 61 (including 2 women). The knowledge of food hygiene for A and D groups was estimated poor (20.34) and high (23.2), respectively, however, based on the statistical data, the difference between them was not significant (P = 0.183). The studied population was also subcategorized in terms of education into 4 groups of A = with primary school certificate (including 27 women), B = with secondary school certificate (including 27 women with the poorest level of knowledge = 19.44), C = with high school certificate (including 21women), and D = with an academic degree (including 20 women with the highest level of knowledge = 23.9). The average scores for knowledge of the studied components, obtained before and after the education, are shown in [Table 3], and the relationship between the total score for knowledge and the demographic data, before and after the education, is presented in [Table 4].

Table 3: Rural homemakers knowledge of food hygiene and safety in relation to each item based on the obtained score

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Table 4: The overall knowledge of rural homemakers in relation to food hygiene (before and after training) based on the investigated variables

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The average scores for attitudes in single and married women before the education were 81.11 and 83.27, respectively, which shows that before the education the single women had more attitudes compared to the unmarried. This score changed after the education to 92.11 and 92.27. The statistical analyses showed no significant difference between the obtained scores for the two groups of women (P = 0.31), which remained almost identical after the education (P = 0.304). A significant difference was detected between the average scores for attitudes in educated and uneducated women by health workers (81.96 and 77.66, respectively) before the educational intervention (P = 0.035), which disappeared after the education (P = 0.143). No significant difference between these scores was reported for women, who used media as an educational means (85.1) and those, who did not (82.71) (P = 0.291). After the education, this figure even became less (P = 0.24). The average scores for attitudes of those who used media as educational tools at a high (85.75) and poor level (83.85) showed no significant difference (P = 0.125) and had almost no change (P = 0.152). Women in the age groups B and C had the poorest (82.75) and highest (84.32) attitudes toward food hygiene. However, the scores had no significant difference (P = 0.516). In the education groups, A and D were recorded the lowest (81.55) and highest (86.66) figures. [Table 5] shows the average scores for attitudes of the studied components, before and after the education and [Table 6] present the relationship between the total score for general attitudes and the demographic data, before and after the education.

Table 5: Rural homemakers attitude of food hygiene and safety in relation to each item based on the obtained score

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Table 6: The overall attitude of rural homemakers in relation to food hygiene (before and after training) based on the investigated variables

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Based on the obtained data from the experiment, we may conclude that the knowledge of food hygiene in rural homemakers of Bisotun, considering parameters such as marital status, training by health workers, use of media for learning goals, and education experienced a positively dramatic change after the educational intervention. Nevertheless, there are still significant differences in some groups in terms of determined parameters.

The difference between the knowledge levels of food hygiene in married and unmarried women of this study might be resulted from the higher level of commitment to the family health and food hygiene in the former and subsequently their serious attention to the corresponding information to improve food quality and hygiene. Our information proved that health workers had failed to increase homemakers knowledge in this field before launching the education. Although they provide rural dwellers with several trainings in family health, disease prevention and environmental health, lack of using posters, pamphlets, and other thought-provoking educational materials undermines their motivation. Using such materials might help to eliminate this problem. We also suggest periodical reeducational classes for health workers to provide them with new and efficient methods for raising awareness in rural homemakers.[19] Women with academic degrees in this village benefited from a higher level of knowledge compared to those with primary school certificate. Higher levels of literacy and education may facilitate the individuals’ development and their proper cooperation with the society in various fields including economics. Only communities with high level of literacy and education may succeed to overcome their problems. Economic factors (such as income), the type of job and education level have a direct and significant relationship with food hygiene.[20],[21] The knowledge level of above 60-year-old women exceeded the other age groups. It might be related to their vast experience, attending the training classes of health workers, and proper communication with them. The knowledge level of under 20-year-old women increased more than other age groups after the educational intervention maybe due to their strong motivations for cooking and householding. Thus, we may conclude that the women of this group benefit from the required readiness to receive education in food hygiene. Knowledge of food hygiene in the studied rural homemakers in all four components was at a good level before the education and reached the “very good” level after it, which approves the effectiveness of the intervention.[22] Use of pamphlets, colored posters, and question and answer sessions to challenge rural women’s mind may be effective to increase knowledge in relation to the fifth component (knowledge of proper practices in vegetables and fruits disinfection). According to the findings of the study, rural homemakers had a “very good” level of attitudes toward the first and second components before the intervention and promoted it after the intervention, which proves their high attitudes toward learning about cross-contamination, foodborne illnesses, and food safety. Level of attitudes toward the third and fifth components was estimated good before the education, and after, it very good toward the fourth and fifth components, but showed no change toward the third one. It might be considered the educational intervention failure in changing attitudes toward corresponding components probably because of the women’s insistence on using traditional methods of food storage.[23],[24] To overcome this failure and change rural homemakers’ mind, we recommend introducing a new method for food storage and proving its effectiveness and meanwhile using of colored posters.[24] Attitudes of educated and 41–60-year-old homemakers were at higher level in comparison with other women that demonstrates the important impact of education and experience in relation to health and hygiene issues. Several researches have been conducted to investigate knowledge and attitudes of students, pupils, and employees in relation to food safety and hygiene. However, the number of interventional studies aimed to investigate the role of education in changing knowledge and attitudes were extremely limited. The results of the semi-experimental research conducted by Khalaj and Mohammadi among the pupils showed that their knowledge and attitudes in relation to nutrition had changed after education at a significant level, which is completely consistent to our research.[25] Jazayeri et al. in their experimental study on knowledge and attitudes of 121 health connectors showed that the test and control groups had no significant difference before the education, but after it, a drastic change had appeared.[26] Shirani in his semi-experimental research on knowledge and practices of 12,345 dwellers in Isfahan province in relation to proper nutrition (2001) reported a drastic increase of the average knowledge in all age and gender groups after 1 year of educational intervention.[27] Bohaty et al. in his study concluded that 8 weeks after the education intervention, the scores for posttest knowledge in relation to osteoporosis, calcium, and Vitamin D was much higher than pretest knowledge, which is statistically considered significant.[28] The results of Oenema and Brug study on feedback strategies for increasing knowledge of individual dietary that was conducted using randomized controlled trials among 304 adult people proved the effectiveness of the planned educational intervention for individuals to increase the consumption of vegetables and fruits and reduce fat intake compared to other educational interventions.[29] Frazao and Allshouse in their study named “Intervention Strategies: Explanation and Discussion” concluded that diet strategies’ improvement needed a combination of strategies and accurate and targeted interventions to change particular practices in different groups of people.[30] Rao et al. in “Food Habits and The influence of Two Different Methods on Knowledge of Nutrition in female adolescent pupils of Hyderabad in India” showed that the knowledge of nutrition in the studied individuals had a significant increase after the educational invention.[31]


The results of the study showed that knowledge and attitudes of food hygiene in the rural dwellers of the studied region were at “good” and “medium” levels, which after the educational intervention reached “very good” level. The attitude levels for all components have detected “good” and “very good,” which promoted after the educational intervention. Therefore, education may be considered an effective solution to increase the level of knowledge and attitudes of rural homemakers in relation to food hygiene. Health workers play the main role in providing the rural dwellers with trainings in hygiene, but according to the obtained data of our study, they failed to fulfill all their responsibilities in various fields including food hygiene properly due to the multiplicity of them. Hence, periodical education (every 6 months) for rural homemakers and even health workers by experts are required for training highly important subjects including food hygiene. Parameter such as gender, age, education… of the individuals must be considered in periodical education.


The authors gratefully acknowledge the Research Council of Kermanshah University of Medical Sciences (Grant Number: 94411) for the financial support.

Financial support and sponsorship

This study was financially supported by Research deputy of University of Medical Sciences, Kermanshah, Iran.

Conflicts of interest

There are no conflicts of interest.



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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_314_17


[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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